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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
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
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
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.
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
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
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.
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.
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
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.
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
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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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
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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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.
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
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.