Category Archives: Prevention and Manage of Surgical Complications

POSTOPERATIVE BLEEDING

Extraction of teeth Is a surgical procedure that presents a severe challenge to the- body’s hemostatic mechanism. Several reasons exist for this change First, the tissues of the mouth and jaws are highly vascular. Second” the extraction of a tooth leaves an open wound, with both soft tissue and bone open, which allows additional oozing  and bleeding. Third, it is almost impossible to apply
dressing material with enough pressure and sealing to prevent additional bleeding during surgery. Fourth, patients tend to play with the area of surgery with their tongues and occaslonallydislodge blood clots, which tiates secondary bleeding. The tongue may also cause secondary bleeding by creating small negative pressures that suction the blood clot from the ·socket. Finally, salvary enzymes may lyse the blood clot before it has .organized
and before the ingrowth of granulation tissue.

BOX 11-9

Prevention of Postoperative Bleeding
I. Obtain history of bleeding.
2. Use atraumatic surgical technique.
3. Obtain good hemostasis at surgery:
4. Provide excellent patient instrutions

As with all complications, prevention of bleeding is, the best way to manage this problem (Box 11-91_ One of the prime factors in preventing bleeding is the taking of a thorough history from tbfl patient regarding this specific
potential problem. Several questions should be asked of the patient concerning any history of bleeding. If affirmative answers to any of these questions are given, the surgeon should take special efforts to control bleeding. The first question that patients should be asked is if they have ever had a problem with bleeding in the past. The surgeon should inquire about bleeding after previous tooth. extractions or previous surgery (such as a tonsillectomy) and persistent bleeding after accidental lacerations. The surgeon must listen carefully to the patient’s answers to the questions, because the patient’s idea of “persistent” may actually be normal. For example, it is quite normal for a socket to ooze small amounts of blood for the first 12 to 24 hours after extraction. However, if ‘! patient relates a history of bleeding that persisted for more than 1 day or that required special attention from the dentist, then the surgeon’s degree of suspicion should be substantially elevated. The surgeon should inquire about any family history . of bleeding. If anyone in the patient’s family has or had
a history of prolonged bleeding,further inquiry about its cause should be pursued. Most congenital bleeding disorders are familial, inherited characteristics. These congenital  disorders vary from very mild to very profound, the latter requiring substantial efforts to control. . The patient should next be asked about anY”medications currently being taken that might interfere with coagulation. Drugs such as anticoagulants may cause
prolonged bleeding  after extraction. Patients receiving anticancer chemotherapy or who are alcoholics may also tend to bleed.’ .  The patient who has a known or suspected coagulopathy should be evaluated by laboratory testing before surgery is performed to determine the severity of the disorder. It is usually advisable to enlist the aid of a hematologist
if the patient  has a familial coagulation disorder.The means to measure the status of intentional anti- . coagulation is to use the International Normalized Ratio (lNR). This value takes into account both the patient’s
prothrombin time (PT) and -the control. Normal anticoagulated status for most medical indications will have an INR of 2.0 to 3.0. It is reasonable to perform extractions on patients who have an INR of 2.5 or less without reducing the anticoagulant dose. With special precautions, it is. reasonably safe to do minor amounts of surgery in’ patients with an INR of up to 3.0, if special local hemostatic measures are taken. Primary control of bleeding during routine surgery  depends on gaining control of all factors that may prolong bleeding. Surgery should be as atraumatic as possible, with clean incisions and gentle management of the Soft tissue. Care should be taken not to crush the soft tissue, because crushed tissue tends to ooze for long periods. Sllilrp bony spicules should be smoothed or removed. All granulation tissue should be curetted from the periapical region of the socket and from around the necks of adjacent teeth and soft tissue flaps. This should.be deferred when anatomic restrictions, such as the sinus or inferior alveolar canal, are present (Fig. 11-12). The wound should be carefully inspected for the presence of any specific bleeding arteries. If such arteries exist in the soft tissue, they should be controlled with direct pressure or, if pressure fails, by clamping the artery with a hemostat and ligating it with a resorbable suture. For most oral surgical procedures, direct pressure over the soft tissue bleeding area for 5 minutes results in complete control. The surgeon should also check for bleeding from thebone. Occasionally, a small, isolated vessel bleeds from a bony fora men. If this occurs, the foramen can be crushed with the closed ends of the hemostat, thereby occluding the. bleeding vessel. Once these measures have been accomplished, the bleeding socket is covered with a damp gauze sponge that has been folded to fit directly into the area from which the tooth was extracted. The patient bites down firmly on this gauze for at least 30 minutes. The surgeon should not dismiss the patient from the office until hemostasis has been achieved. This requires that the surgeon check the patient’s extraction socket about 15 minutes after the completion of surgery. The patient should open the mciuth widely, the gauze should b e rermoved.vand the area should be inspected carefully for any persistent oozing.Initial control should have been achieved. New damp gauze is then folded and placed into position, and the patient is told to leave-it in place for an additional 30 minutes.  If bleeding persists but careful inspection of the socket reveals that it is not of an arterial origin, the surgeon should tak e additional measures to achieve hemostasis. Several different materials can be-placed in the socket to help gain hemostasis (Fig. 11-13). The most commonly used and the least expensive is the absorbable gelatin sponge (e.g., Gelfoam). This. material is placed in the extraction socket and held in place with’ a figure eight suture placed over the socket. The absorbable gelatin sponge forms a scaffold for the formation of a blood clot, and the suture helps maintain the sponge in position during the coagulation process. A gauze pack is then placed over the top of the socket and. is held with pressure. A second material that can be used to control bleedingis oxidized regnerated cellulose (e.g., Surgicel). This material promotes coagulation better than the absorbable gelatin sponge, bemuse it can be packed into the socket under pressure. The gelatin sponge becomes very friable when wet and cannot be packed into a bleeding socket. When the cellulose is packed into the socket, it almost always causes delayed healing of the socket. Therefore, packing the socket with cellulose is reserved for more persistent bleeding. If the surgeon has special concerns about the patient’sability to clot, a liquid preparation of topical thrombin (prepared from bovine thrombin) can be saturated onto a gelatin sponge and inserted into the tooth socket. The thrombin bypasses all steps in the coagulation cascade and helps to convert fibrinogen to, fibrin enzymatically, which formsa clot. The sponge with the topical thrombin is secured in place with a figure-eight suture. A gauze pack is placed over the extraction site in the usual fashion.A final material that can be used to help control a bleeding socket is collagen. Colla gen promotes platelet aggregation and thereby helps accelerate blood coagulation.Collagen is currently available in several different forms. Microfibular collagen (e.g., Avitene) is available as a .fibular material that is loose and fluffy but can be

packed into a tooth socket and held in by suturing and gauze packs, as with the other materials. A more highly cross-linked collagen is supplied as a plug (e.g., Collaplug) or as-a tape (e.g., Collatape). These materials are more
readily packed into a socket (Fig. 11-14) and are easier to use. They are also more expensive. Even after primary hemostasis has been achieved, patients occasionally call the dentist with bleeding from the extraction site, ‘referred to as secondary’ bleeding. The patient should be told to rinse the mouth gently with very cold water, then place appropriate-sized g~uze over the area and bite firmly. The patient should sit quietly for 30 minutes, biting firmly on the gauze. If the bleeding persists, the patient ‘should repeat the cold rinse and bite down on a damp tea bag. The tannin in the tea will frequently help . stop the bleeding. If neither of these techniques is successful, the patient should return to the dentist.The surgeon must have an orderly, planned regimen to control this secondary bleeding. The patient should be positioned in the dental chair, and all blood, saliva, and fluids should be suctioned from the mouth. Such patients will frequently have large “liver clots” in their mouth, which must be removed. The surgeon should visualize the bleeding site carefully with good light to determine
the precise source of bleeding. If it is clearly seen to be ageneralized oozing, the bleeding site is covered with a folded, damp gauze sponge held in place with firm pressure by the surgeon’s finger for at least 5 minutes.

This measure is sufficient to control most bleeding. The reason for the> bleeding is usually some secondary trauma that is potentiated by the patient’s continuing to suck on the area or to spit blood from the mouth instead of continuing to apply pressure with a gauze sponge. If 5 minutes of this treatment does not control the bleeding, the surgeon must administer a local anesthetic so that the socket can be treated more aggressively. Block
techniques are to be encouraged instead of local infiltration techniques. Infiltration with solutions containing epinephrine cause vasoconstriction and may control the bleeding temporarily. However, when the effects of the
epinephrine dissipate, rebound hemorrhage with recurrent bothersome bleeding may occur. Once local anesthesia has been achieved, the surgeon
should gently curette out the tooth extraction socket and suction all areas of old blood clot. The specific area of bleeding should be identified as clearly as possible. As with primary bleeding, the soft tissue should be checked for diffuse oozing versus specific artery bleeding. The bone tissue should be checked for small nutrie t artery bleeding or general oozing. The same measures described for control of primary bleeding should be used. The surgeon must then decide if a hemostatic agent should be inserted into the bony socket. The use of an absorbable gelatin sponge with topical thrombin held in position with a figure-of-eight stitch and reinforced with application of firm pressure from a small, damp gauze pack is standard for local control of secondary bleeding. This technique works well in almost every bleeding socket. In many. situations an absorbable gelatin sponge and gauze pressure are adequate. The-patient should be given specific instructions on how to apply the gauze packs directly to the bleeding site should additional bleeding occur. Before the patient with secondary bleeding is discharged from the office, the surgeon should monitor the patient for at least 30 minutes to ensure that adequate hemostatic control has been achieved. If hemostasis is not achieved by any of the local measures just discussed, the surgeon should consider performing additional laboratory screening tests to determine if the patient has a profound hemostatic defect. The dentist usually requests a consultation from a hematologist, who orders the typical screening tests. Abnormal- test results will prompt the hematologist to investigate the patient’s hemostatic system further. A final hemostatic complication relates to intraoperative and postoperative bleeding into the adjacent soft tissues. Blood that escapes into tissue spaces, especially subcutaneous tissue spaces, appears as bruising of the overlying soft tissue 2 to 5 days after the surgery. This bruising is termed ecchymosis (see Chapter 10). removal.  careful asepsis and thorough wound debridement a fter surgery can best achieve prevention of infection after surgical flap procedures. This means that the ‘area of bone removal under the flap must be copiously irrigated with saline and that all foreign debris must be removed with a curette. Some patients are predisposed to postoperative wound infections and should be given perioperative prophylactic antibiotcs (see Chapter 15).

Wound Dehiscence

Another problem of delayed healing is wound dehiscence (Box 11-10). If a soft tissue flap is replaced and sutured without an adequate bony foundation, the unsupported soft tissue flap ‘often sags and separates along the line of incision. A second cause of dehiscence is suturing the wound under tension. If the soft tissue flap is sutured under tension, the sutures cause ischemia of the flap margin with subsequent ’tissue necrosis, which allows the suture to pull through the flap margin and results in wound dehiscence. Therefore sutures should always be placed in tissue without tension and tied loosely enough to prevent blanching of the tissue.  A common area of exposed bone after tooth extraction is the internal oblique ridge. After extraction of the first and second molar, during the initial healing, the lingual flap becomes stretched over the internal oblique (mylohyoid) ridge. Occasionally, the bone will perforate through the thin ‘mucosa, causing a sharp projection of  one in the area. The two major treatment options are (1) to leave the projection alone, or (2) to smooth it with bone file. If the area is left to heal untreated, the exposed bone ‘Will
slough off in 2 to 4 weeks. If the irritation of the sharp bone is low, this is the preferred method. If a bone file is .used, 110 flap should be elevated, because this will result in an increased amount of exposed bone. The file is used only to smooth off the sharp projections of the bone. This procedure usually requires local anesthesia. Patients who are -quite annoyed by the sharp bone will usually choose this method .

Dry Socket

Dry socket or alveolar osteitis is delayed healing but is not associated with an infection. This postoperative complication causes moderate-to-severe pain but Is without the usual signs ‘and symptoms of infection, such as ever, swelling, and erythema. The term dry socket describes  he appearance of the tooth extraction socket when the pain

BOX 11-10

Prevention of Wound Dehiscence
1. Use aseptic technique.
2. Perform atraumatic surgery.
3. Close incision over intact bone.
4. Suture without tension.

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 the bony surfaces
of the ‘socket are exposed. The exposed bone is extremely sensitive and is the source of the pain. The dull” aching’ pain is moderate to severe, usually throbs, and frequently radiates to the patient’s ear.The area of the socket has a bad odor  the patient frequently complains of a bad taste.The cause of alveolar osteitis is not absolutely clear, but it appears to be the result of high levels of fibrinolytic activity in and around the tooth extraction socket. This fibrinolytic activity results in lysis of the blood dot and subsequent exposure of the bone. The fibrinolytic activity may be the result of 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 relatively rare (2% of extractions), but it is quite frequent after the removal of impacted mandibular third molars (20% of extractions). ,
Prevention of the dry socket syndrome ,requires,that the surgeon minimize trauma and bacterial contamination in the area.of surgery. The surgeon should perform atraumatic surgery with clean incisions and soft tissue
reflection. After the surgical procedure, the wound should be thoroughly debrided and irrigated with large quantities of saline. Small amounts of antibtottcs (e.g., tetracycline) placed in the socket alone or OI:l a gelatin
sponge may help to decrease the incidence of dry socket in mandibular third molars. The incidence of dry socket can also be decreased by preoperative and postoperative ,rinses with antimicrobial mouth rinses, such as chlorhexidine. Well-contralled studies indicate that the incidence
of dry socket after impacted mandibular third molar surgery can be reduced by up to Se The treatment of alveolar osteitis is dictated by the
single therapeutic goal of relieving the patient’s pain during the period of healing. If the patient receives no treatment, no sequela other than continued pairi exists (treatment does not hasten healing).  Treatment is straightforward and consists of gentle irrigation and insertion of a medicated ‘dressing. First, the. tooth socket is gently irrigated with saline. The socket should not be curetted down to bare bone, because this increases both the amount of exposed bone and the pain. Usually the entire blood clot is not lysed, and the part that is intact should be retained. The socket is carefully suctioned of all excess saline, and a small strip of  soaked with the medication Is inserted into the socket. The medication contains the following principal ingredients: eugenol, which obtunds the pain from the bone tissue; a topical anesthetic, such as benzocaine and a carrying vehicle, such as balsam of Peru. The medication can be made by the surgeon’s pharmacist or can he obtained as a commercial preparation from dental surgery houses. The medicated gauze is gently inseted into the socket,   nd the patient usually experiences profound relief from pain within 5 minutes. The dressing is changed every-day or every other day for the next 3 to 6 days, depending on the severity of the pain. The socket is gently irrigated with saline at each dressing change. Once the patient’s pain decreases, the dressing should not be replaced, because it acts as a foreign body and further prolongs wound healing.

OROANTRAL COMMUNICATLONS

Removal of maxillary molars occasionally results in comt munication between the oral cavity and the maxillary sinus. If the maxillary sinus is large, if no bone exists between the roots of the teeth and the maxillary sinus, and if the roots of the tooth are widely divergent, then it is increasingly probable that a portion of the bony floor of the sinus will be removed with the tooth. If this complication occurs, appropriate measures are necessary to prevent a variety of sequelae. The two sequelae of most
concern are post operative maxillary sinusitis and formation of a chronic oroantral fistula. The probability that either of these two sequelae will occui is related to the  size of the oroantral communication and the management
Qf the exposure. As with all complicatlons.  prevention is the easiest and
most efficient method of managing the situation. Preoperative radio graphs must be carefully evaluated for the tooth-sinus relationship whenever maxillary molars are to be extracted. If the sinus floor seems to be very close to the tooth roots and the tooth roots are widely divergent, the surgeon should avoid a closed forceps extraction and perform a surgical removal with sectioning of tooth roots (see Fig. 11-8). Large amounts of force should be avoided in the removal of such maxillary molars (Box 11-8).
Diagnosis of the oroantral communication can be made in several ways: The first is to examine the tooth once it is removed. If a section of bone is adhered to the root ends of the tooth, the surgeon can be relatively certain
that a communication between the sinus and mouth exists. If a small amount of bone or no bone adheres to the molars, a communication may exist anyway. To confirm the presence of a communication, the best technique. is to use the nose-blowing test. Pinching the. nostrils together occludes the patient’s nose, and the patient is asked to blow gently through the nose while the surgeon observes t he area of the tooth extraction. If a communication exists, there will be passage of air through the . tooth socket and bubbling of blood in the socket area.

BOX 11-8

Prevention of Oroantral Communications
1. Conduct thorough preoperative radio graphic examination. .
2. lJie surgical extraction early and section roots.
3. Avoid excess apical pressure

After the diagnosis of oroantral communication has been established, the surgeon must determine the approximate size of the communication, because the treatment will depend on the size of the opening. If the communication is small (2 mm in diameter or less), no additional surgical treatment is necessary. The surgeon should take measures to’ ensure the formation of a high-quality blood clot in the socket and then advise the patient-to take sinus precautions to prevent dislodgment of the blood clot.
Sinus precautions are aimed at preventing increases or decreases in the maxillary sinus air pressure that would dislodge the dot. Patients should be advised to avoid blowing the nose, violent sneezing, sucking on straws,
and smoking. Patients who smoke and who cannot stop (even temporarily) should be advised to smoke in small puffs, not in deep drags, to avoid pressure changes. The surgeon must not probe through the socket .into
the sinus with a periapical curette or a root tip pick. It is possible that the bone of the sinus has been removed without perforation of the sinus lining. To probe the socket with an instrument might unnecessarily lacerate the membrane. Probing of the communication may also introduce foreign material, including bacteria, into the sinus and thereby further complicate the situation. Probing of the communication is therefore absolutely contraindicated. If the opening between the mouth and sinus is of moderate size (2 to 6 mm), additional measures should be taken. To help ensure the maintenance of the blood clot in the area, a figure-of-eight suture should be placed over the tooth socket (Fig. 11-11). The patient should also be told to follow sinus precautions. Finally, the patient should be prescribed several medications to help lessen the possibility that maxillary sinusitis will occur, Antibiotics, usually penicillin or clindamycin, should be prescribed for 5 days. In addition, a decongestant nasal spray should be prescribed to shrink the nasal mucosa to keep the ostium of the sinus patent. As long as the ostium is patent and normal sinus drainage can occur, sinusitis and sinus infection are less likely. An oral decongestant is also sometimes recommended. If the sinus opening is large (7’mm or larger), the dentist
should consider closing the sinus communication with a flap procedure. This usually requires that the patient be referred to an oral and maxillofacial surgeon, because flap , development and closure of a sinus opening are somewhat complex procedures that require skill and experience. The most commonly used flap is a buccal flap. This technique mobilizes buccal soft tissue to cover the opening and provide for a primary closure. This technique should be performed as soon as possible, preferably

the same day in which the opening occurred. The same sinus precautions and medications are, usually required, . (see Chapter 19)~ The recommendations just described hold true for ‘ patients who have no preexisting sinus disease. If a communication does occur, it is important that t’he dentist inquire specifically about a history of sinusitis and sinus
infections. If the patient has a history of chronic sinus disease, even, ~all oroantral communications will heal . poorly and may result in permanent oroantral communication. Therefore creation of an oroantral communication in patients with chronic sinusitis is cause for referral
to an oral and maxillofacial surgeon for definitive care (see Chapter 19). ,
The -majority of oroantral communications treated in the methods just recommended will heal, uneventfully. Patients should be followed up carefully for several weeks to ensure that this has occurred. Even patients who return within a few’ days with a small communication usually heal spontaneously if no maxillary sinusitis exists. These patients should be followed up closely and referred to an oral and maxillofacial surgeon if the communication persists for longer than 2 weeks. Closure of oroantral fistulae is important because air, water, food, and bacteria go from the oral cavity into the sinus” often causing a chronic sinusitis condition. Additionally, if the patient i~ wearing a full maxillary denture, suction is not as strong; therefore retention of the denture is compromised.

 

 

 

 

INJURIES TO ADJACENT STRUCTURES

During the process of tooth extraction, it is possible to injure adjacent tissues. The prudent surgeon preoperatively evaluates all adjacent anatomic areas and designs a surgical procedure to prevent injury to these tissues.

Injury to Regional Nerves

The branches of the fifth cranial nerve, which provide innervation to the mucosa and skin, are the structures most likely to beinjured during extraction. The most frequently involved specific branches are the mental nerve, the lingual nerve, the buccal nerve, and the nasopalatine nerve. The nasopalatine and buccal nerves are frequently _.sectioned during the creation of flaps for removal of impacted teeth. The area of sensory innervation of these two nerves is relatively small, and reinnervation of the
affected area usually occurs rapidly. Therefore the nasopalatine and long buccal nerves can be surgically sectioned without sequelae or complications. Surgical removal of mandibular premolar roots or
impacted mandiputar premolars and periapical surgery in

BOX 11-6

Prevention of Nerve Injury
1. Be aware of nerve anatomy in surgical area.
2. Avoid making incisions or affecting periosteum in· nerve area.

performed with great care. If the mental nerve is injured, the patient will have an anesthesia or paresthesia of the lip and chin. If the injury is the result of flap reflection or simple manipulation, the altered sensation usually disappears in a few weeks to a few months. If the mental nerve is sectioned at its exit from the mental foramen or torn along its course, it is likely that mental nerve function, will not return, and the patient will have a per.manent state of anesthesia. If surgery is to be performed in the area of the mental nerve or the mental foramen, it is imperative that surgeons have a keen awareness of the potential morbidity from injury to this nerve (Box 11-6). If surgeons have any question concerning their ability to perform the indicated surgical procedure, they should refer the patient to an oral and maxillofacial surgeon. If a three-corner flap is to be used in the area of the mental nerve, the vertical releasing incision must be placed far enough anterior to avoid severing any portion of the mental nerve: Rarely is
it advisable to make the vertical releasing incision at the inter dental papilla between the canine and first premolar. The lingual nerve is anatomically located directly against the lingual aspect of the mandible in the retromolar pad region. The lingual nerve rarely regenerates if it is severely
traumatized, Incisions made in the retro molar pad region of the mandible should be placed to avoid severing this nerve. Therefore incisions made for surgical exposure of impacted third molars or of bony areas in the posterior molar region should be made well to the buccal aspect of the mandible.
Prevention of  injury to the lingual nerve is of paramount importance far controlling this difficult complication. Finally, the inferior alveolar nerve may be traumatized along the course of its intrabony canal. The most common place of injury is the area of the mandibular. third molar. Removal of impacted third molars may crush or sharply . injure the nerve in its canal. This complication is common enough during the extraction of third molars that it Is important to inform patients on a routine basis that it is a
possibility. The surgeon must then take every precaution possible to avoid injuring the nerve during the extraction.

Injury to .Temporomandibular Joint

Another major structure that can be traumatized during an extraction procedure in the mandible is the temporo-: mandibular .joint (TMJ). Removal of mandibular molar teeth frequently requires the application of a substantial amount of force. If the jaw is inadequately supported diuing
the extraction, the patient may experience pain in this region. Controlled force and adequate support of the jaw prevents this. The use of a bite block on the contralateral

BOX 11-7

Prevention of Injury to Temporomandibular Joint
1. Support mandible during extraction.
2. Do-not open mouth too widely.

side may provide adequate balance of forces so that injury and pain do not occur (Box 11-7). The surgeon must also support the jaw as described earlier. If the patient complains of pain in the TMJ immediatefy after the extraction procedure, the surgeon should recommend the use of moist heat, rest for the jaw, a soft diet, and 1000 mg of aspirin every 4 hours for several days. Patients who cannot tolerate aspirin should be given an aspirin substitute, such as other NSAIDs or acetaminophen.

 

INJURIES TO OSSEOUS STRUCTURES

Fracture of Alveolar Process

The extraction of a tooth requires that the surrounding alveolar Done be expanded to allow an unimpeded pathway for tooth. removal. However, in some situations the bone fractures and is removed with the tooth instead of
expanding. The most likely cause of fracture of the alveolar process is the use of excessive force with forceps, which fractures large portions of cortical plate. 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 removed so that the tooth can be easily delivered. If this principle is not adhered to and the dentist  continues to use excessive or uncontrolled forcer fracture of the bone will probably occur. The most likely places for. bony fracture are the buccal cortical plate o~er the maxillary canine, the buccal cortical

BOX 11-5

Prevention of Fracture of Alveolar Process

1. Conduct thorough preoperative clinical and radio graphic examination.
2. Do not use’ excessive force.
3. Use surgical (i.e., open) extraction technique to reduce force required

plate over the maxillary molars (especially the first molar), the portions of the “floor of the maxillary sinus associated with maxillary molars, the maxillary tuberosity, and the labial bone on mandibular incisors (Fig. 11-7). All of these bony injuries are caused by excessive force from the forceps. The primary method of preventing these fractures is to perform a careful preoperative examination of the alveolar process, both clinically and radio graphically (Box 11-5). Surgeons should inspect the root forrnt of the tooth to be removed and assess the proximity of the roots .to the maxillary sinus (Fig. 11-8). They should also check the thickness of the buccal corticalplate overlying the tooth to be extracted lFig. 11-9). If the roots diverge widely, if they lie close to the sinus, or if the patient has a heavy buccal cortical bone, surgeons must take special measures to prevent fracturing excessive portions of bone. Age is a factor to be considered, because the bones. of older patients arc likely to be less elastic and therefore more likely to fracture rather than expand. The surgeon who preoperatively determines that a high probability exists for bone fracture. should consider performing the extraction by the surgical technique·
Using this method the surgeon can remove a smaller

more controlled ‘amount of bone, which results in more rapid healing and a more ideal ridge form for prosthetic reconstruction. When the maxillary molar lies close  to the maxillary sinus, surgical exposure of the tooth, with sectioning of the tooth roots into two or three portions, will prevent the removal of a portion of the maxillary smus floor. This prevents the formation of a. chronic oroantral fistula, which requires secondary procedures to close. In summary, prevention of fractures of large portions of the cortical plate depends on preoperative radio graphic and clinical assessment, avoidance of the use of excessive amourits of uncontrolled force, and the early decision to perform an open extraction with removal of controlled amounts of bone and sectioning of multirooted teeth. During a forceps extraction, if the appropriate amount of tooth mobilization does not occur early, then the wise and prudent dentist will alter the treatment plan to the surgical technique instead of pursuing the closed method.
Management of fractures of the alveolar bone takes several different routes, depending on the type and severity of the fracture: If the bone has been completely removed from the tooth socket along with the tooth, it should not be replaced, The surgeon should simply make sure that the soft tissue has been replaced and reposit ionod over there maining bone to prevent delayed healir must also smooth any sharp edges that  have  caused by the fracture. If such sharp e the surgeon should reflect a small amount )’ and use a bone file to-round off the sharp teeth.

The surgeon who has beeri supporting the alveolar process with the fingers during the extraction will feel the fracture of the buccal cortical plate when it occurs. At this time the bone remains attached’to the periosteum and
will heal if it can be separated from the tooth’ andleft attached to the overlying soft tissue. The surgeon must carefully dissect the bone with its attached associated soft tissue away from the tooth. For this procedure the tooth must be stabilized with the forceps, and a small sharp instrument, such as a Woodson periosteal elevator, should be used to elevate the buccal bone from the tooth root. It is important to realize that if the soft tissue flap is reflected from the bone, the blood supply to the overlying bone will be severed and the bone will then undergo necrosis. Once the bone and’ soft tissue have been elevated from the tooth, the tooth is removed and the bone and soft tissue flap are reapproximated and secured with ·sutures. When treated in this fashion, it is highly probable that the bone will heal in a more favorable ridge form for prosthetic reconstruction than if the bone. had been removed along with the tooth. Therefore it is worth the special effort to dissect the bone from the tooth.

Fracture of Maxillary Tuberosity

tuberosity area is a situation of special concern. The maxillary tuberosity is especially important forthe construction of a stable retentive maxillary denture. If a large portion of this tuberosity is removed along with the maxillary tooth, denture stability. may be compromised. The fracture o f the maxillary tuberosity most commonly results from extraction of an erupted -maxillary third molar or from a second molar if it happen’s to be the last tooth in the arch (Fig. 11-10). ‘ tf this type of fracture occurs during an extraction, treatment is similar to that just discussed for other bony

fractures. The surgeon using finger support for the alveolar process during the fracture (if the bone remains attached to the periosteum) should take extreme measures to ensure the survival of that bony segment. If at all possible the bony segment should be dissected away from the tooth and the tooth removed in the usual fashion. The tuberosity is then stabilized with sutures as previously indicated. However, if the tuberosity is excessively mobile and cannot be dissected.from the tooth, the surgeon has several
options. The first option is to splint the tooth being extracted to adjacent teeth and defer the extraction for 6 to 8 weeks, during which time the bone will heal. The tooth is then extracted with an open surgical technique.
The second option is to section the crown of the tooth from the roots and allow the tuberosity and tooth root section to heal. After 6 to 8 weeks the surgeon can reenter the area and remove the tooth roots in the usual fashion. If the maxillary molar tooth is infected, these two techniqu es should be used with caution. If the maxillary tuberosity is completely separated from the soft tissue, the usual steps are to smooth the sharp
edges of tile remaining bone and to replace and suture the -remaining soft tissue. The surgeon must carefully check for an oroantral communication and treat as necessary,Fractures of the maxillary tuberosity should be viewedas a serious complication. The major therapeutic goal of
management is’ to maintain the fractured bone in place and to provide the best possible environment for healing.This may be a situation that can best-be handled by referral to an oral and maxillofacial surgeon.

INJURIES TO ADJACENT TEETH

When the dentist extracts a tooth, the tocus ot attention is on that particular tooth and the application of forces to luxate and deliver it. When the surgeon’s total attention is thus focused, likelihood of injury to the adjacent teeth increases. The surgeon should mentally step back from time to time to survey the entire surgical field to prevent injury to adjacent teeth.

Fracture of Adjacent Restoration 

The most common injury to adjacent teeth is the inadvertent fracture of either a restoration or a severely carious tooth while the surgeon’ is attempting to luxate the tooth to be removed with an elevator (Fig. 11-5). If a large restoration exists, the surgeon should warn the patient preoperatively about the possibility of fracturing it during the extraction. Prevention of such a fracture is primarily achieved by avoiding application of instrumentation and force on the restoration (Box 11-3). This means that the straight elevator should be used with great caution or not
used at all to luxate the tooth before. extraction. If a

BOX 11-3

Prevention of Injury to Adjacent Teeth
1. Recognize potential to fracture large restoration.
2. Warn patient preoperatively.
3. Employ judicious use’ of elevators.
4. Ask assistant to warn surgeon of pressure on adjacent teeth. .

restoration is dislodged or ,fractured, the surgeon should make sure’ that the ‘displaced restoration is removed from, the mouth and does not fall into the empty tooth socket. Once the surgical procedure has been completed, ‘the injured tooth should be treated by placement of a temporary restoranon. The patient should be informed that , the fracture has occurred and that a replacement restoration must be placed (see Chapter 12). . • Teeth in the opposite arch may also be injured as a ‘result of uncontrolled tractional forces. This usually occurs when buccolingual forces inadequately mobilize a tooth and excessive tractional forces are used. The tooth suddenly releases from the socket, and the forceps strikes
against the teeth  of the opposite arch and chips or fractures a cusp. This is ‘more likely to occur with extraction of lower teeth, because these teeth may require more vertical tractional forces for their delivery, especially when using the no. 23 (cowhorn) forceps. Prevention of this type of injury can be accomplished by several methods. First and primary, the, surgeon should avoid the use of excessive tractional forces. The tooth should be, adequately luxated with apical, buccolingual, and rotational forces to minimize the need for tractional forces. Even when this is done, however, occasionally a tooth releases unexpectedly. The surgeon or assistant should
protect the teeth of t he opposite arch by simply holding a finger or suction tip against them to absorb the blow should the forceps be released in that direction. If such an injury occurs, the tooth should be smoothed or restored as necessary to keep the patient comfortable until a permanent
restoration can be constructed.

Luxation of Adjacent Teeth

extracted is’ crowded and has overlapping adjacent teeth, such as is commonly seen in the mandibular incisor region, intn, narrow forceps such as the no, 2H6 forceps, may be useful for the extraction (Fig. 11-6). Forceps with broader beaks .should be avoided, because it will cause injury and luxation of the adjacent teeth. If an adjacent tooth is luxated or partially avulsed, the treatment goal is to reposition the tooth “into its appropriate
position and stabilize it so that adequate healing occurs. This usually requires that the tooth simply be repositioned in the tooth socket and left alone. The occlusion should be checked to ensure that the tooth has not been displaced into a hypererupted and traumatic occlusion. Occasionally, the luxated tooth is very mobile. If this is the case, the tooth should be stabilized with the least possible rigid fixation to maintain the tooth in its position. A simple silk suture that crosses the occlusal table and is sutured to the adjacent gingiva is usually sufficient. Rigid fixation with circumdental wires and, arch bars results in increased chances for external toot resorption and ankylosis of the teeth: therefore it , should usually be avoided (see Chapter 23):

Extraction of Wrong Teeth

A complication that every dentist believes can never happen-but happens surprisingly often-is extraction of the wrong tooth. This should never occur if appropriate attention is given to the planning and execution of the
surgical procedure.This problem may be the result of inadequate attention
to the preoperative assessment. If the tooth to be extracted is grossly carious, it is less likely that the wrong tooth will be removed. The wrong tooth is most commonly extracted when the dentist is asked to remove
teeth for orthodontic purposes, especially from patients , who are in mixed dentition stages and whose orthodon-

BOX 11-4

Prevention of Extraction of Wrong Teeth

1. Focus attention on procedure.
2. Enlist patient and assistant to ensure correct tooth is  being removed.
3. Check, then recheck, to confirm correct tooth.

tists have asked for unusual extractions. Careful preoperative planning and clinical assessment of which’ tooth is to be removed before the forceps is applied is the main method of preventing this complication (Box 11-4). If the wrong tooth is extracted and the dentist realizes this error immediately, the tooth should be replaced , immediately into the tooth socket. If the extraction is for orthodontic purposes, .the dentist should contact the
orthodontist immediately and discuss whether or not the tooth that was removed can substitute for the. tooth that should have been removed, If the orthodontist believes the original tooth must be removed, the correct extraction should be deferred for 4 or 5 weeks, until the fate of the
replanted tooth can be assessed. If the wrongfully extracted tooth has regained its attachment to the alveolar process, then’ the originally planned extraction can proceed. The surgeon should not extract the contralateral
tooth until a definite alternative treatment plan is made. If the surgeon does not recognize that the wrong tooth was extracted until the patient returns for a postoperative visit, little can be done to correct the problem. Replantation -of the extracted tooth after it has dried cannot-be
.successfully accomplished. When the wrong tooth is extracted, it is important to inform the patient, the patient’s parents (if the patient is
a minor), and any other dentist involved with the patient’s care, such as the orthodontist. In some situations the orthodontist may’ be able to adjust the treatment plan so that extraction of the wrong toothnecessitates
only a minor adjustment.

 

 

 

 

COMPLICATIONS WITH THE TOOTH BEING EXTRACTED

Root Fracture

The most common complication associated with the 00 h being extracted is fracture of its roots. Long, ed, divergent roots that lie in dense bone are most
of be fractured. The main method of preventing

BOX 11-2

Prevention of Root and Displacement Fracture
1. Always plan for root fracture.
2. Use surgical (i.e., open) extraction if high probability of fracture.
3. Do not use strong ‘apical force on.broken root.

fracture of roots is to perform an open extraction technique and to remove bone to decrease the amount of force necessary to remove the’ tooth (Box 11-2). Recovery of the fractured root with a surgical approach is discussed’
in Chapter 8.

Root Displacement.

The tooth root that is most commonly displaced into unfavorable anatomic spaces is the maxillary molar root, which is forced into the maxillary sinus. If a root of a maxillary molar is being removed, with a straight elevator
being used with excess apical pressure ~s a wedge in the periodontal ligament space, the tooth root can be displaced into the maxillary sinus. If this occurs, the surgeon must make several assessments to prescribe the appropriate treatment. First, the surgeon must identify the size of the ‘root lost jnto the sinus. It may be a root tip of several millimeters, an entire tooth root, or the entire tooth. The surgeon must next assess if there has been any infection of the tooth or periapical tissues. If the tooth is not infected, management is easier tharr if the tooth has been acutely infected. Finally, the surgeon must assess the preoperative condition of the maxillary sinus. For the patient who .hasa healthy maxillary sinus, it is easier to manage a displaced root than if the sinus has been chronically infected.  If the displaced tooth fragment is a small (2 or 3 mm) root tip and the tooth and sinus have no.preexisting infection, the surgeon should make a minimal attempt at removing the root. First, a radiograph of the fractured
tooth root should be taken to document its position and. size. Once that has been accomplished, the surgeon should irrigate through the small opening in the socket’ apex and then suction the irrigating solution from the sinus via the  socket. This occasionally flushes the root apex from the sinus through the socket. The surgeon should check the suction solution and confirm radiographically that the root has been removed. If this tech:
nique is not successful, no  additional surgical procedure should be performed through the socket, and the root tip should be left in the sinus. The small, non infected root tip can be left in place, because it is quite unlikely that it will cause any troublesome sequelae. Additional surgery in this situation will cause more patient mor- . bidity than leaving the root tip ill situ. If the root tip is  ‘left in the sinus, measures should be taken similar to those taken when leaving any root tip in place. The patient’ must be informed of the decision and given proper follow-up Instructions. The oroantral communication should be managed as discussed later, with a figure-of-eight suture over the socket, sinus precautions, antibiotics, and a nasal spray to prevent infection and keep the ostium open. The most likely
occurrence is that the  root apex will fibrose onto the sinus membrane with no subsequent problems. If the’ tooth root is infected or the patient has chronic sinusitis, the patient should be referred to an oral and maxillofacial
surgeon for removal of the root tip.If a large root fragment or the entire tooth is displaced into the maxillary sinus, it should be removed (Fig. 11-4)

The usual method is a Caldwell-Luc approach into the’ maxillary sinus in the canine fossa region and then removal of the tooth. The oral and axillofacial surgeon (to whom the patient should’ be referred) performs this  procedure (see Chapter 19). Impacted maxillary third molars are occasionally displaced into the maxillary sinus (from which they are removed via a Caldwell-Luc approach) or posteriorly into the infratemporal space. During elevation of the tooth, the elevator may force the tooth posterioriy through the periosteum into the infratemporal fossa. The tooth is usuallylateral to the lateral pterygoid plate and inferior to the lateral pterygoid muscle. If good access and light are available, the surgeon should make a single cautious effort to retrieve the tooth with a hemostat. The tooth. is usually
not visible, and blind probing will result in further displacement. If the tooth is not retrieved after a single effort, the incision should be closed and the operation stopped. The patient should be informed that the tooth has been displaced and will be removed later. Antibiotics should be given to help decrease the possibility of an infection, and routine postoperative care should be provided. During the initial healing time, fibrosis occurs and stabilizes the tooth in a rather firm position. The tooth is removed 4 to 6
weeks later by an oral and maxillofacial surgeon. The displaced tooth lies medial to the ramus of the mandible and may interfere with wide opening ~of the mouth. In addition, the occurrence of a late infection is possible. Although possible, it is very unlikely that the tooth will migrate after initial fibrosis has occurred. If no mandibular restriction exists, the patient may elect not to have the tooth removed. If this decision is made, the surgeon
must document that the patient understands the situation and the ‘potential complications. Fractured mandibular molar roots that are being removed
with apical pressures may be displaced through the lingual cortical plate and into the submandtbularras, cial space. The lingual cortical bone over the roots of the molars becomes thinner as tt progresses posteriorly.
Mandibular third molars, for example, frequently have dehiscence in the overlying lingual bone and. may be actually sitting in the submandibular space preoperatively. Even small amounts of apical pressure result in displacement of the root into that ‘Space. .Prevention of displacement
into the submandibular space is primarily achieved by avoiding all apical pressures when removing the mandibular roots. Pennant-shaped elevators, such as the Cryer, are used to elevate the broken tooth root. If the root disappears during the root removal, the dentist should make a single
effort to remove it. The index finger of the left .hand is inserted onto the lingual aspect of the floor of the mouth in an attempt to place pressure against the lingual aspect of the mandible and force the root back into the socket. If this works, the surgeon may be able to tease the root out of the socket with a root tip pick. If this effort is not successful on the initial attempt, the dentist should abandon the procedure and refer the patient to an oral and maxillofacial surgeon. The usual, definitive procedure of removing such a root tip is to reflect a soft tissue flap on e lingual aspect of the mandible and gently dissect the

overlying mucoperiosteum until the root tip can be found. As with teeth that are displaced into the maxillary sinus, if the root fragment is small and was not infected . preoperatively, the oral and maxillofacial surgeon elect to leave the root in its position, because surgical retrieval of the root may be an extensive procedure.

Tooth lost into Oropharynx

Occasionally, the crown of a tooth or an entire tooth might be lost down the oropharynx. If this occurs, the patient should be turned toward the dentist, into a mouth-down position, as much as possible. The suction device can then be used to help remove the teeth. The patient should be encouraged to cough and spit the tooth’ out onto the floor. In spite of these efforts, the tooth may be swallowed or aspirated. If the patient has no coughing or respiratory distress, it is most likely that the tooth was swallowed and has traveled down the esophagus into the stomach. However, if the patient has a violent episode of coughing that continues, the tooth may have been aspirated beyond the larynx into the trachea. In either case the patient should be transported to an emergency room and chest and abdominal radiographs taken to determine the specific location of the tooth. If the tooth has been aspirated, consultation should. be requested regarding the possibility of removing. the tooth with a bronchoscope. The urgent management of aspira- . tion is to maintain the patient’s airway and breathing. Supplemental oxygen may be appropriate if respiratory
distress ap0pears to be occurring. If the tooth has been swallowed, it is highly probable that it will pass through the gastrointestinal. (GI) tract
‘within 2 to 4 days. Because teeth are not usually jagged or sharp,  unimpeded passage occurs in almost all situations. However, it may be prudent to have the patient go to an emergency room and have a radio graph of the abdomen taken to confirm the tooth’s presence in the GI tract instead of in the respiratory tract. Follow-up radio graphs are  probably not necessary, because the usual fate of swallowed teeth is passage.

 

INJURIES TO ADJACENT STRUCTURE

During the process of tooth extraction, it is possible to injure adjacent tissues. The prudent surgeon preoperatively evaluates all adjacent anatomic areas and designs a surgical procedure to prevent injury to these tissues.

BOX 11-6

Prevention of Nerve Injury

1. Be aware of nerve anatomy in surgical area.
2. Avoid making incisions or affecting periosteum in nerve area

the area of the mental nerve and mental for a men must be performed with great care. If the mental nerve is injured, the patient will have an anesthesia or paresthesia of the lip and chin. If the injury is the result of flap reflection or simple manipulation, the altered sensation usually disappears in a few weeks to a few months. If the mental nerve is sectioned at its exit from the  mental foramen or torn along its course, it is likely that mental nerve function, will not return, and the patient will have a per.manent state of
anesthesia. If surgery is to be performed in the area of the mental nerve or the mental foramen, it is imperative that surgeons have a keen awareness of the potential morbidity from injury to this nerve (Box 11-6). If surgeons have any question concerning their ability to perform the indicated surgical procedure, they should refer the patient to an oral and maxillofacial surgeon. If a three-corner flap is to be used in the area of the mental nerve, the vertical releasing incision must be placed far enough anterior to avoid severing any portion of the mental nerve: Rarely is it advisable to make the vertical releasing incision at the interdental papilla between the canine and first premolar. The lingual nerve is anatomically located directly against
the lingual aspect of the mandible in the retromolar pad region. The lingual nerve rarely regenerates if it is severely traumatized, Incisions made in the retromolar pad region of the mandible should be placed to avoid severing this nerve. Therefore incisions made for surgical exposure of impacted
third molars or of bony areas in the posterior molar region should be made well to the buccal aspect of the mandible. Prevention of injury to the lingual nerve is of paramount importance far controlling this difficult  complication. Finally, the inferior alveolar nerve may be traumatized along the course of its intrabony canal. The most common place of injury is the area of the mandibular. third molar. Removal of impacted third molars may crush or sharply . injure the nerve in its canal. This complication is  common enough during the extraction of third molars that it Is important to inform patients on a routine basis that it is a possibility. The surgeon ust then take every precaution
possible to avoid injuring the nerve during the extraction.

 

 

 

 

 

 

 

 

 

 

 

 

INJURIES TO OSSEOUS STRUCTURE 

Fracture of Alveolar Process

The extraction of a tooth requires that the surrounding alveolar Done be expanded to allow an unimpeded pathway for tooth. removal. However, in some situations the bone fractures and is removed with the tooth instead of
expanding. The most likely cause of fracture of the alveolar process is the use of excessive force with forceps, which fractures large portions of cortical plate. 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 removed so that the tooth can be easily delivered. If this principle is not adhered to and the dentist continues to use excessive or uncontrolled forcer fracture of the bone will probably occur. The most likely places for. bony fracture are the buccal cortical plate o~er the maxillary canine, the buccal cortical.

BOX 11-5 

Prevention of Fracture of Alveolar Process

1. Conduct thorough preoperative clinical and radio graphic examination.
2. Do not use’ excessive force.
3. Use surgical (i.e., open) extraction technique to reduce force required.

plate over the maxillary molars (especially the first molar), the portions of the “floor of the maxillary sinus associated with maxillary molars, the maxillary tuberosity, and the labial bone on mandibular incisors (Fig. 11-7). All of these bony injuries are caused by excessive force from the forceps. The primary method of preventing these fractures is to perform a careful preoperative examination of the alveo- .lar process, both clinically and radio graphically (Box 11-5). Surgeons should inspect the root forrn of the tooth to be removed and assess the proximity of the roots .to the maxillary sinus (Fig. 11-8). They should also check the thickness of the buccal corticalplate overlying the tooth to be extracted lFig. 11-9). If the roots diverge widely, if they lie close to the sinus, or if the patient has a heavy buccal cortical bone, surgeons must take special measures to prevent fracturing excessive portions of bone. Age is a factor to be .considered, because the bones. of older patients arc likely to be less elastic and therefore more likely to fracture rather than expand. The surgeon who preoperatively determines that a high probability exists for bone fracture. should consider performing the extraction by the surgical technique. Using this method the surgeon can remove a smaller,

 

more controlled ‘amount of bone, which results in more rapid healing and a more ideal ridge form for prosthetic reconstruction. When the maxillary molar lies close to the maxillary sinus, surgical exposure of the tooth, with sectioning of the tooth roots into two or three portions, will prevent the removal of a portion of the maxillary smus floor. This prevents the formation of a. chronic oroantral  fistula, which requires secondary procedures to close. In summary, prevention of fractures of large portions of the cortical plate depends on preoperative radio graphic and clinical assessment, avoidance of the use of excessive amourits of uncontrolled force, and the early decision to perform an open extraction with removal of controlled amounts of bone and sectioning of multi rooted teeth. tooth mobilization does not occur early, then the wise and prudent dentist will alter the treatment plan to the surgical technique instead of pursuing the closed method. Management of fractures of the alveolar bone takes several
different routes, depending on the type and severity of the fracture: If the bone has been completely removed from the tooth socket along with the tooth, it should not be replaced, The surgeon should simply make ~ure that
the soft tissue has been replaced and reposit ionod over the remaining bone to prevent delayed healirus Teeth.l must also smooth any sharp edges that  have Ilien caused by the fracture. If such sharp edge the surgeon should reflect a small amount ) tussiue and use a bone file to-round off the sharp teeth.

The surgeon who has been supporting the alveolar process with the fingers during the extraction will feel the fracture of the buccal cortical plate when it occurs. At this time the bone remains attached’to the periosteum and will heal if it can be separated from the tooth’ andleft attached to the overlying soft tissue. The surgeon must carefully dissect the bone with its attached associated soft tissue away from the tooth. For this procedure the  tooth must be stabilized with the forceps, and a small sharp instrument, such as a Wood son periosteal elevator, should be used to elevate the  buccal bone from the tooth root. It is important to realize that if the soft tissue flap is reflected from the bone, the blood supply to the overlying
bone will be severed and the bone will then undergo necrosis. Once the bone and’ soft tissue have been elevated from the tooth, the tooth is removed and the bone and soft tissue flap are re approximated and secured with ·sutures. When treated in this fashion, it is highly probable that the bone will heal in a more favorable ridge form for prosthetic reconstruction than if the bone. had been removed along with the tooth. Therefore it is worth the special effort to dissect the bone from the tooth.

Fracture of Maxillary Tuberosity

Fracture of a large section of bone in the maxillary tuberosity area is a situation of special concern. The maxillary tuberosity is especially important forthe construction of a stable retentive maxillary denture. If a large portion of this tuberosity is removed along with the maxillary tooth, denture stability. may be compromised. The fracture of the maxillary tuberosity most commonly results from extraction of an erupted -maxillary third molar or from a second molar if it happen’s to be the last tooth in the arch (Fig. 11-10).  tf this type of fracture occurs during an extraction, treatment is similar to that just discussed for other bonyfractures. The surgeon using finger support for the alveolar process during the fracture (if the bone remains attached to the periosteum) should take extreme measures to ensure the survival of that bony segment. If at all possible the
bony segment should be dissected away from the tooth and the tooth removed in the usual fashion. The tuberosity is then stabilized with sutures as previously indicated. However, if the tuberosity is excessively mobile and cannot be dissected.from the tooth, the surgeon has several options. The first option is to splint the tooth being extracted to adjacent teeth and defer the extraction for 6 to 8 weeks, during which time the bone will heal. The tooth is then extracted with an open surgical technique. The second option is to section the crown of the tooth from the roots and allow the tuberosity and tooth root section to heal. After 6 to 8 weeks the surgeon can reenter the area and remove the tooth roots in the usual fashion. If the maxillary molar tooth is infected, these two techniques should be used with caution. If the maxillary tuberosity is completely separated from the soft tissue, the usual steps are to smooth the sharp edges of tile remaining bone and to replace and suture the -remaining soft tissue. The surgeon must carefully check for an oroantral communication and treat as necessary,
Fractures of the  maxillary tuberosity should be viewed as a serious complication. The major therapeutic goal of management is’ to maintain the fractured bone in place and to provide the best possible environment for healing. This may be a situation that can best-be handled by referral to an oral and maxillofacial surgeon.