Category Archives: Prevention and Manage of Surgical Complications

Luxation of Adjacent Teeth

Luxation of Adjacent Teeth

Inappropriate use of the extraction instruments may luxate the adjacent tooth. This is prevented by [udicious use of force with elevators and orceps. If the tooth to been 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):

FIG. 11-6 A. No. 151 forceps, too wide to grasp premolar to be extracted without luxating adjacent teeth. 8, MaXillary root forceps, which can be adapted easily to tooth for extraction.

FIG. 11-6 A. No. 151 forceps, too wide to grasp premolar to be extracted without luxating adjacent
teeth. B MaXillary root forceps, which can be adapted easily to tooth for extraction.

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 anq 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 extract- ‘ed 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 tooth necessitates only a minor adjustment.

Fracture of Adjacent Restoration

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. .

FIG 11.5Mandibularfirst molar. If it is to be removed, surgeon must take care not to fracture amalgam in second premolar with ~Ievators or forceps.

FIG 11.5 Mandibularfirst molar. If it is to be removed, surgeon must take care not to fracture
amalgam in second premolar with ~Ievators or forceps.

restorat ion is dislodged or ,fractured, the surgeon should make SlITt’ that the ‘displaced restoration is removed from, the mouth and does not fall into the empty tooth socket. Once the surgical p.!..ocedure 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 the 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.

 

 

 

 

 

 

 

 

 

 

 

Tooth lost into Oropharynx

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 radio graphs 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 aspiration is to maintain the patient’s airway and breathing. Supplemental oxygen may be appropriate if respiratory
distress appears 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 radiographs
are probably not necessary, because the usual fate of swallowed
teeth is passage.

INJURIES TO ADJACENT TEETH

When the dentist extracts a tooth, the focus of 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.

Root Displacement.

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 .has a 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 radio graph 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 radio graphically
that the root has been removed. If this technique 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 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 maxillofacial 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 usually lateral 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 to oth 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 man~ibte and gently dissect the

FIG. 11-4 A, large root fragment displaced into maxillary sinus. Fragment should be removed with Caldwell-luc approach. 8, Tooth in maxillary sinus is maxillary third molar that was displaced into sinus during elevation of tooth. This tooth must be removed from sinus, probably via a Caldwell-luc approach.

FIG. 11-4 A, large root fragment displaced into maxillary sinus.
Fragment should be removed with Caldwell-luc approach. 8, Tooth
in maxillary sinus is maxillary third molar that was displaced into sinus
during elevation of tooth. This tooth must be removed from sinus,
probably via a Caldwell-luc approach.

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 may
elect to leave the root in its position, because surgical retrieval of the root may be an extensive procedure.

COMPLICATIONS WITH THE TOOTH BEING EXTRACTED

COMPLICATIONS WITH THE TOOTH BEING EXTRACTED 

Root Fracture

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

FIG. 11-2 Small straight elevator can be used as shoehorn to luxate broken root. When straight elevator is used in this position, hand must be securely supported 9n adjacent teeth to prevent inadvertent slippage 01 instrument from tooth and subsequent injury to adjacent tissue.

FIG. 11-2 Small straight elevator can be used as shoehorn to luxate
broken root. When straight elevator is used in this position, hand
must be securely supported 9n adjacent teeth to prevent inadvertent
slippage 01 instrument from tooth and subsequent injury to
adjacent tissue.

FIG. 11-3 A, Abrasion of lip as result of shank of bur rotating on soft tissue. Wound should be kept. covered with antibiotic ointment. B, Healing should occur rapidly, as observed in this pPlotograph taken 5 days later

FIG. 11-3 A, Abrasion of lip as result of shank of bur rotating on soft tissue. Wound should be kept.
covered with antibiotic ointment. B, Healing should occur rapidly, as observed in this pPlotograph
taken 5 days later

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.

Stretch or Abrasion Injury

Stretch or Abrasion Injury 

Abrasions or burns of the lips and corners ,of the mouth are usually the result of the rotating shank of the bur rubbing on the soft issue (Fig. 11~3). When the surgeon is focused on the cutting end of the bur, the assistant should be aware of the location of the shank of the bur in relation to the cheeks and lips. If such an abrasion does develop, the dentist should advise the patient to keep it covered with Vaseline or an antibiotic ointment. It is important that the  patient keeps the ointment only on the abraded area and not spread onto intact skin, because it is quite likely to result in a rash. These abrasions usually take 5 to 10 days to heal. The patient should keep the area moist.with the ointment during the entire healing period to prevent eschar formation; .scarrtng, and delayed healing, as well as to keep the area reasonably comfortable.

Tearing Mucosal Flap

Tearing Mucosal Flap

The most common soft tissue injury is the tearing pf the mucosal flap during surgical extraction of a tooth. This is usually-the result of an inadequately sized envelope flap, which is retracted beyond the tissue’s ability to stretch
(Fig. 11-1). This results in a tearing, usually at one end of the incision.  Prevention of this complication is twofold: (1) create adequately sized flaps to prevent excess tension. On the flap, and (2, use small amounts of retraction for,.ce on the flap. If tear does occur in the flap, the flap should
be carefully re positioned once the surgery is complete. In most patients, careful suturing of the tear results in adequate but delayed healing. If the tear is especially jagged, the surgeon may consider excising the edges of the join flap to create a smooth flap margin for closure. This latter step should be performed with caution, because excision of excessive amounts of tissue leads to closure of the wound under tension and probable wound dissidence. If the area’ of surgery is near the apex of a tooth, an increased incidence of envelope-flap tearing exists as a result of excessive retractional forces. In this situation a release incision to create a three-cornered flap should be used to gain access to the bone

SOFT TISSUE INJURIES

SOFT TISSUE INJURIES

Injuries to the soft tissue of the oral cavity are almost always the result of the surgeon’s lack of adequate attention to the delicate nature of the mucosa and the use of excessive and uncontrolled force. The surgeon must continue to pay careful attention to the soft tissue while working primarily on the bone and tooth structure (Box 11-1).

 

PREVENTION OF COMPLICATIONS

PREVENTION OF COMPLICATIONS

It is axiomatic that the best and easiest way to manage a complication is to prevent it from happening. Prevention of surgical complications is best accompllshed by a thor-hpreoperative assessment and comprehensive treatment plan. Only when these are routinely performed can fie surgeon expect to have minimal complications. It is I portant to realize that even with such planning, comIt is axiomatic that the best and easiest way to manage a comphcatlon is to prevent it from happening. Prevention of surgical complications is best accomplished by a thor- hpreoperative assessment and comprehensive treatment plan. Only when these are routinely performed can fie surgeon expect to have minimal complications. It is I portant to realize that even with such planning, compltcatiofis occasionally occur. In situations in which the dentist has planned carefully, thecomplication is often expected and can be managed in a routine manner For example, when extracting a maxillary first premolar, which has long thin roots, it is far easier to remove thebuccal root than the palatal root. Therefore the surgeon uses more force toward the buccal root than toward the.palatal root. If a root does fracture, it is then the buccal root rather than the palatal root, and the subsequent retrieval is easier. Surgeons must perform surgery that is within their own ability. Surgeons must therefore carefully evaluate their training and ability before deciding to perform a specific surgical task. It is inappropriate for a dentist with . limited experience in .the management of impacted thirdmol   to undertake the surgical extraction of a deeply cmlulded tooth. he incidence of operative and postoperative cornplications is unacceptably high in this situation. Surgeons must be cautious of unwarranted optimism, which clouds their judgment and prevents them from delivering the best possible care to the patient. The dentist must keep in mind that referral to a specialist is an option that should always be exercised if the planned surger J ts beyond the dentist’s own skill level. In sorn mations this is not only a moral obligation l also a medico legal responsibility. In planning a surgical procedure,’ the first step is always a thorough review of the patient” medical history. Several of the complications to be discussed in this chapter are caused by inadequate attention to medical histories that would have revealed the presence of a complicating factor. Patients with compromised physical status will have local surgfcal complications that ‘could have been prevented had the surgeon taken a more thorough medical history. O ne of the primary ways to prevent complications is by taking adequate radio graphs and reviewing them cinefully (see Chapter 7). The radio graph must include the entire area of surgery, including the apices of the roots of the teeth to be extracted .and the local and’ regional anatomic structures, such as the maxtllary sinus and the inferior alveolar canal. The surgeon must look for the presence of abnormal tooth root morphology. After care  full examination of the radio graphs, the surgeon must occasionally alter the treatment plan to prevent the complications  that might be anticipated with a routine forceps (closed) extraction. Instead, the surgeon should consider  surgical approaches to removing teeth in such cases. After an adequate medical history has been taken and the radio graphs have been analyzed, the surgeon must do the preoperative planning. This is not simply a preparation of a detailed surgical plan but is also a plan for. managing patient anxiety and pain and postoperative recovery (instructions and modifications of normal activity for the patient). Thorough preoperative instructions’ and explanations for the patient are essential in preventing the majority of complications that occur in the postoperative period. If the instructions are. not thoroughly explained or their importance made clear, the patient is less likely to follow them. Finally, to keep complications at a minimum, the surgeon must always follow the basic surgical principles .. There should always be clear visualization and access to the operative field, which requires adequate light, adequate soft tissue reflection (including lips, cheeks, tongue, and soft tissue flaps), and adequate suction. The teeth to be removed must have an unimpeded pathway for removal. Occasionally, bone must be removed and teeth must be sectioned to achieve this goal. Controlled force is of paramount importance; this means “finesse,” not “force.” The surgeon must follow the principles of asepsis, atraumatic handling of tissues, hemostasis, and thorough debarment of the wound after the surgical procedure. Violation of these principles leads to an increased incidence and severity of surgical complications.

BOX 11-1

Prevention of Soft Tissue injuries

1. Pay strict attention to soft tissue injuries.
2. Develop adequate-sized flaps.
3. Use minimal force for retraction of soft tissue

Prevention and Manage of Surgical Complications

CHAPTER OUTLINE

PREVENTION OF COMPLICATIONS
SOFT TISSUE INJURIES
Tearing Mucosal Flap
Puncture Wound of Soft Tissue
Stretch or Abrasion Injury
COMPLICATIONS WITH THE TOOTH BEING EXTRACTED
Root Fracture
Root Displacement
Tooth Lost into Oropharynx
INJURIES TO ADJACENT TEEni
Fracture of Adjacent Restoration
Luxation of Adjacent Teeth
Extraction of Wrong Teeth

INJURIES TO OSSEOUS STRUCTURES
Fracture of Alveolar Process
Fracture of Maxillary Tuberosity
INJURIES TO ADJAcENT STRUCTURES
Injury to Regional Nerves
Injury to Temporomandibular Joint
OROANTRAL COMMUNICATIONS
POSTOP£RATIVE BLEEDING
DELAYED HEALING AND INFECTION
Infection
Wound Dehiscence
DrySocket
FRACTURES OF THE MANDIBLE
SUMMARY

‘This chapter discusses the variety of complication  of oral surgical procedures. It is divided. into two sections, intraoperative and postoperative complications. These are surgical, not medical, complications the latter are discussed in Chapter 3.