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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

COMPLICATIONS OF ORAL SURGERY

As with all surgical procedures complications can occur at each of the 3 stages.

1st stage. Before surgery due to - inadequate surgical planning - poor case selection medically compromised pt. who is a poor surgical risk.

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

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. 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

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

INTRA-OPERATIVE COMPLICATIONS
The most common complications that may occur during surgery are as follows
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Dental complications Soft tissue complications Bone complications Nerve complications Mx sinus complications Instrument breakage

DENTAL COMPLICATIONS

Fracture of teeth Displacement of teeth Swallowing /Aspiration of teeth

FRACTURES OF TEETH

Crown due to - gross caries - excessive force - brittle 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

Management :

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

DISPLACEMENT OF TEETH

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

MANAGEMENT

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

SWALLOWING OR ASPIRATION

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

Swallowing has no serious consequence as the tooth is readily excreted, 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 - urgent referal to ENT for pharyngoscopic removal of tooth Lower airway chest xray is essential & referral for endoscopic removal of tooth.

SOFT TISSUE COMPLICATIONS

Trauma Primary haemorrhage Surgical Emphysema

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

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PRIMARY HAEMORRHAGE

Primary haemorrhage from surrounding soft tissues may be persistent in cases of

Excessive surgical trauma 2. Inflamed tissues 3. Underlying bleeding tendency due to drug therapy, anticoagulants. Management Check record of bleeding disorders Local measures: Direct pressure Suturing Gelfoam, Surgicel, topical thrombin
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SURGICAL EMPHYSEMA

Emphysema is the accumulation of air in tissues which in dental surgery may be caused by - use of high speed air rotor handpiece - increased intra-oral pressure through sneezing, coughing or nose blowing after minor oral surgery - use of hydrogen peroxide in the surgical wound

Management surgical emphysema crackles when palpated & usually resolves with time. Extensive - may lead to infection - Antibiotics

BONE COMPLICATIONS

Haemorrhage # Maxillary Tuberosity TMJ Dislocation # Mandible

HAEMORRHAGE

Blood vessels in the BONE may be controlled with:

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

FRACTURE OF MAXILLARY TUBEROSITY

Predisposing factors: - Lone standing maxillary molar in elderly pts - Ankylosed maxillary molars - 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

TMJ DISLOCATION
Predisposing factors

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

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

FRACTURE OF THE MANDIBLE

Fractures in the mandible are caused by: - excessive extraction forces on teeth in unsupported mandible - poor surgical technique - excessive bone removal

Predisposing causes Buried tooth in an otherwise atrophic mandible Osteolytic pathology cysts, tumors Brittle bone osteogenesis impefecta, osteopetrosis

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

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NERVE COMPLICATIONS

Lingual Nerve Damage Inferior Alveolar Nerve Damage Mental Nerve Damage

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 - hematoma formed by direct penetration of nearby blood vessels by the needle Management Explanation + reassurance. Nerve will recover naturally in a few days

LINGUAL NERVE DAMAGE

Lingual nerve damage may be caused by :


- excessive retraction of lingual tissues - pressure from tongue retractor leaning against the lingual alveolus - lingual split technique used for removal of lower third molar - inadverent cutting of nerve with bur / scalpel

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: - The roots may directly breach the inferior alveolar canal resulting in direct injury to the nerve on removal of the tooth - On attempted extraction, the root tip is displaced directly into the canal causing injury - Inadverent severence of the nerve with bur.

MENTAL NERVE DAMAGE

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

General management if Nerve Injuries


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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. The best prognosis for return of nerve function is if the required surgery is performed within 3 months of injury.

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MAXILLARY SINUS COMPLICATIONS

Breach of Mx Sinus Displacement of tooth into Mx Sinus

BREACH / BREAK OF MAXILLARY SINUS FLOOR An oro-antral communication can result from: - The roots extend well beyond the sinus floor - Extraction is difficult & traumatic injudicous use of root elevators - Lone standing molar - Tooth is ankylosed - There is periapical pathology ie cyst / granuloma extending 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.

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 - refer to a specialist who may opt for immediate closure with buccal advancement flap if sinus is clear of infection Instruct pt. not to blow nose for 7-10 days + analgesics + antibiotics + nasal decongestants & mucolytics

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

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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.

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.

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INSTRUMENT BREAKAGE

INSTRUMENT BREAKAGE

Needles, burs + elevator tips are likely to break. If the instrument is easily accessible then remove it immediately. 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

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POST OPERATIVE COMPLICATIONS

Alveolar Osteitis Infections Haemorrhage Necrosis of Mucous Membrane Persistent Pain

ALVEOLAR OSTEITIS Also called dry socket, alveolagia, ASD Classic presentation is that - it occurs about 3 days after extraction - very painful with inability to eat - 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.

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

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

MANAGEMENT

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

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 - palatal injection under excessive force - poor flap design - compromised blood supply due to excessive stretching,tearing, base too narrow - poor wound care - systemic disorders neutropenia

Management Local wound debridement + toilet of area to allow healing by secondary intention

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 - causalgia ( phantom tooth pain ) - psychogenic pain

Management 1. Reassess orignal diagnosis - 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

THANK YOU

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, a surgical procedure should be considered.

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