3. PRE-OPERATIVE COMPLICATIONS
MEDICAL HISTORY
Consider allergies, bleeding disorders etc.
DENTAL HISTORY
Consider if the patient has had difficult
extractions in the past, are they anxious etc.
INFECTION, ACCESS AND
VISIBILITY?
4. INTRA-OPERATIVE COMPLICATIONS
FAILURE OF LOCAL ANAESTHETIC
FAILURE TO REMOVE THE TOOTH
TRAUMA TO HARD TISSUES
TRAUMA TO SOFT TISSUES
DISPLACEMENT OF TEETH
DISPLACEMENT OF TMJ
ORO-ANTRAL COMMUNICATIONS
5. FAILURE OF LOCAL ANAESTHETIC
Acute infections prevent the Local Anaesthetic from working
Reasons why LA doesn’t work when there is an acute infection……
Acutely inflamed tissues are more vascular, therefore the solution is removed more
quickly from the site.
The acidic conditions impedes the dissociation of the active components.
Inflammation increases the nerve threshold and therefore a higher concentration of LA
solution is needed to anaesthetise the nerve.
MANAGEMENT
Consider block injections; the infra-orbital block, the posterior superior alveolar block, the
ID block.
Increase the LA solution given or a use concentrated LA solution such as 5% lignocaine.
• Intra-ligamentary injections down the periodontal membrane will help
If you have absolute failure of anaesthesia, prescribe antibiotics and analgesics . Wait for 3-
4 days to allow the infection to progress from acute to chronic before attempting extraction.
You might want to consider GA
6. FAILURE TO REMOVE THE TOOTH
• INCORRECT
FORCEPS/ELEVATORS
• BONE SCLEROSIS
• DIVERGENT ROOTS
• HYPERCEMENTOSIS
• BLADES OF THE FORCEPS
NOT THE RIGHT WIDTH
FOR THE POINT OF
CONTACTASSESS THE CAUSE
OF DIFFICULTY
• APPLICATION OF CORRECT
ELEVATORS/FORCEPS
• FOR MOLAR TEETH, DIVIDE
THE TOOTH AND DELIVER
ROOTS INDEPENDENTLY
• SURGICAL REMOVAL
POSSIBLE
SOLUTIONS
7. TRAUMA TO HARD TISSUESFRACTUREOFTHEALVEOLARBONE
Occurs when the
alveolar bone gets
included in the
forceps.
Fracture of the
alveolar buccal
plate can occur
when leaning
buccally to deliver
the tooth .
Convergent roots
or ankylosed roots
may retain alveolar
bone when
delivering the
tooth.
MANAGEMENT
IF THE FRACTURED BONE
HAS LOST ITS PERI-
OSTEAL ATTACHMENT:
The blood supply has
been lost thus the
fragment should be
removed to avoid
necrosis and infection
of the bone.
MANAGEMENT
IF THE FRACTURED BONE
IS STILL ATTACHED TO
THE PERI-OSTEUM:
Squeeze the socket
together and push the
fractured bone into its
original position
8. TRAUMA TO SOFT TISSUES
DAMAGE
TO SOFT
TISSUES
Damage to the gingivae
should be avoided by
good technique. Always
ensure that the forceps
are applied subgingivally.
Protect the lower lip so
that it doesn’t get
crushed by handles of
the forceps or burnt by a
surgical hand piece.
Uncontrolled and
careless use of forceps
can traumatise the
tongue and floor of
mouth .
9. DISPLACEMENT OF TMJ
Usually caused by not
supporting the
mandible adequately
during the extraction.
Using props and gags in
the mouth which are
too large can also
displace the TMJ.
DISLOCATION
OF THE TMJ
IMMEDIATELY REPLACE THE DISLOCATED
TMJ
Stand in front of the patient.
Place your thumbs on the external oblique
ridge intra-orally.
Place your forefingers behind the angle of
the mandible extra-orally.
Manoeuvre the TMJ back into position by
pushing down with your thumbs and up
with your fingers.
Post-op instructions should include a soft
diet for 1 week, and advise not to open
their mouth too wide.
MANAGEMENT
10. ORO-ANTRAL COMMUNICATIONS
• OAC: Is a communication between the oral
cavity and the antrum which is not lined by an
epithelium.
• OAF: Is a communication between the oral
cavity and the antrum which is lined by an
epithelium.
• It takes ~48 hours for the epithelium tract to
form.
11. ORO-ANTRAL COMMUNICATIONS
CAUSES
•When the roots of the upper
posterior teeth are in close
proximity to the antral floor.
•When the extraction of upper
posterior teeth has been
traumatic.
•Bulbous curved long roots
•Surgical extractions.
•Hypercementosis / Ankylosis
of upper posterior teeth which
make extractions difficult.
•Antral pneumatisation around
a lone standing tooth.
•Cysts/infection associated
with upper posterior teeth.
•Neoplasm
DIAGNOSIS
• If you suspect an OAC,
ask the patient to blow
whilst you occlude the
nose: Bubbling
indicates an OAC.
• Patients complain of
nasal regurgitation of
liquids which is
unilateral
• Altered nasal speech
• Bad taste (can also be
from a dry socket)
• Unilateral nasal
discharge
• Recurrent sinusitis on
the affected side
TREATMENT
• ANTRAL REGIME:
• Antibiotics
• Analgesics
• Decongestants
• Mucolytics
• CLOSURE WITH A FLAP:
• Buccal Advancement
Flap
• Buccal Fat Pad
• Palatal Rotation Flap
13. HAEMORRHAGE
REACTIONARY HEMORRHAGE
When the vasoconstrictor from the local
anaesthetic wears off, there is a rebound
effect with vasodilatation to cause
bleeding.
MANAGEMENT:
Visualise the site of haemorrhage. Apply
pressure with gauze or use a local
anaesthetic with vasoconstrictor….Use
surgicel and place a suture if need be!!
15. PAIN
Most patients will suffer from pain after an
extraction. Therefore, recommend simple analgesia.
Use SOCRATES to diagnose post-op pain.
16. PAIN
Causes of post-extraction pain include:
• Pain from the extraction.
• Dry socket.
• Retained root or bone spicules.
• Damage to adjacent teeth causing pulpal pain.
• Damage to adjacent soft tissues which are then
sore.
• Dislocated mandible.
• Bony fractures.
17. INFECTION
It results from the failure of the clot being retained due to vigorous
rinsing or lytic organisms breaking down the clot.
Dry sockets occur more frequently in patients who smoke.
Classically presents as severe throbbing pain +/- lymphadenopathy.
It tends to have an onset of 3-5 days after extraction.
Grey/White bone is visible.
MANAGEMENT
Irrigate the socket with Chlorhexidine, and pack in alvogyl. Review in
a few days time
DRY
SOCKET
