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Painless removal of the tooth or

tooth roots with minimal trauma to


the adjacent structures so that
wound will heal uneventfully with
minimal post-operative prosthetic
complications.
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PREVENTION OF COMPLICATIONS
IN GENERAL
PREVENTION
PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE
INTRA-OPERATIVE COMPLICATIONS
1. Inability to move the tooth
CAUSE: May be due to anatomical
peculiarity of the tooth
Sclerosis of bone due to chronic
long standing infection in that region.
Ankylosis of root [rare]
PREVENTION : A thorough examination of the
radiograph of the tooth
MANAGEMENT : Advice radiograph ,
examine carefully.
Consider trans alveolar extraction in case
of dilacerated roots.
2. FRACTURE OF TOOTH [CROWN / ROOT ]
CAUSES: A. Wrong forceps used for extraction.
B. Inappropriate force applied for extraction.
D. Grossly carious tooth.
PREVENTION :
Select the correct forceps for the tooth, get the grip rite.

Forceps should be wedged into the PDL space as apically
as possible to create a centre of rotation apically.
MANAGEMENT :
If the root is fractured at the apical third, use an
apexoelevator to slowly tease the root out of the socket
If only a small piece of tooth is remaining, it may even be
left behind to resorb slowly.

If the tooth was infected or involved in any pathology, it
may be absolutely necessary to remove it.
3.FRACTURE OF ALVELOAR PROCESS
CAUSE: This can happen if excessive force is applied
while extracting the tooth.
PREVENTION:

While luxating a tooth, use only minimal force to
move the tooth in the socket,the tooth should not be
forced out with excessive force.

MANAGEMENT:
sometimes only small pieces of tooth of bone may
come out while extracting the tooth. This may be
removed carefully along with the root. In some cases
a large piece of the entire buccal or lingual cotical
plates may rupture .In such cases it may be necessary
to replace the bone in its position with its periosteal
attachment intact
4.FRACTURE OF MAXILLARY TUBEROSITY
CAUSE:
while extracting an upper third molar the tuberosity may fracture
with it. This may be due to excessive distal force that is applied while
extracting
PREVENTION:
An upper third molar is best removed with an elevator, Force applied
in the correct direction will prevent fracture of the tuberosity with
tooth
Management :
Once the tuberosity has fractured,it is first important to check
whether it has created oro-antral communication,if created should be
managed accordingly
5.FRACTURE OF JAW:
Improper use of instruments while extracting teeth can lead to fracture of the
jaw
Ex: if crossbar elevator is used with excessive uncontrolled force in the mandibular
third molar region it can lead to fracture of angle of mandible
PREVENTION:
Great care should be taken along with the controlled force while extracting the
teeth.
MANAGEMENT:
If the fractures are noticed the fragments are reduced,wired and intermaxillary
fixation is made.
Defentitive surgery may be done later
6.MUCOSAL LACERATIONS:
CAUSE:
Slipping of the forces elevators,tearing of flap due to
inadequate size of flap.Mucosal tear due to
inadequate reflection of the gingiva from tooth, this
may lead to mucosa also being removed along with the
tooth
PREVENTION: use controlled force while applying
elevators, use the other hand to retract tissues in such
away that is away from fieled of operation
MANAGEMENT:
if the mucosa gets lacerated it can be
approximated and suture if it is not under tension
7.PUNCTURE WOUNDS ON MUCOSA
SURROUNDING TOOTH
CAUSE:
Puncture wounds again take place due to slipping of
the instruments
PREVENTION:
Place the forceps carefully on the tooth, check before
applying force to exact the tooth
8.ABRASIONS OR BURNS ON SOFT TISSUES:
CAUSE:
Use of rotary instruments to get heated and burn
tissues that they are in constant contact with.

PREVENTION:
Use of cheek retractors and other retractors to keep
soft tissue away from the field of surgey

MANAGEMENT:
Advice the patient to maintain good oral hygeine and
do warm saline rinses.prescribe analgesics
SOFT TISSUE INJURIES
TEARING OF MUCOSAL FLAPS
CAUSES
Inadequately sized flap
Improper reflection and
retraction of flap
PREVENTION
Create adequate sized flap
with releasing incisions when
reqd
Use small amount of retraction
force.
MANAGEMENT
Careful suturing
Excising jagged edges
MANAGEMENT:
if the restoration or the crown of adjacent tooth is
dislodged patient must be informed, a temporary
restoration is placed on the adjacent tooth and patient
recalled after a week for permanent treatment
10.Luxation of the adjacent tooth:
CAUSE:a single conical rooted adjacent tooth is in the
danger of inadvertent luxation with the tooth being
extracted if uncontrolled force is applied with an
elevator to the adjacent tooth

PREVENTION:
on the preoperative radiograph check the root of the
adjacent tooth, if it is a conical single slender root
MANAGEMENT:
if the adjacent tooth has been luxated or avulsed it
should be replaced in the socket and splinted for a
period of 3-6 for healing
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11.OROANTRAL COMMUNICATION
CAUSE:
Floor of maxillary Antrum extending into the alveolus is one of the
main reasons for the formation of an oroantral fistula after
extraction.
If a maxillary premolar or molar root is fractured and
excessive bone is removed in attempting to remove the
root,oroantral communication is created,same applies to the
maxillary posterior teeth.
In case of largely divergent roots extending into the floor of
antrum, there are chances of oroantral
commumnication.tuberosity fracture and blind instrumentation in
this region can also lead to oroantral communication.
PREVENTION: Carefully check a pre operative
radiograph for the proximity of maxillary antrum to the
roots of the upper teeth
MANAGEMENT: Firstly it is important to diagnose an
oroantral communication. Various tests are done to
confirm it. They include
A. NOSE BLOWING TEST: The anterior nares are
compressed and the patient is asked to blow from the
nose. An increase in intra nasal pressure is seen as a
whistling sound from the extraction socket.
B. Escape of air bubbles from the orifice is indicative.
C. A cotton wisp is held at the suspected opening, and
the patient is asked to blow from the nose. The
deflection of the cotton wisp is indicative.
D. MOUTH MIRROR FOGGING TEST:
Fogging of mouth mirror placed at the opening is
indicative.
E. Unilateral epistaxsis may be a suggestative of oro antral
communication.
Management:
a. pressure pack
b. visualize:stop of the bleeding
c. Local anasthetic packs: ADRENALINE
d. Sutures
e. cautery: the area is dried as much as possible and a
hot ball burnisher may be used to cauterize
f. Ligation
g. gel foam:which acts by disrupting platlets and
establishing frame work with fibrin strands to create a
clot
h. Oxidised cellulose: release cellulosic acid, which leads
to formation of artificial clot
i. Bone wax: placing a small piece of bone wax firmly on
the spot of bleeding causing the blocking the bleeding
vessel

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MANAGEMENT
Small communication i.e lesser than 2
mm
Mid sized communication i.e 2-6 mm
Large communications ie above
6mm
:
CAUSE: During extraction if the tooth just seems to suddenly
slip away and disappear, this complication should be
suspected. They may into slip into sub mandibular space
below the mylohyoid muscle.
PREVENTION: Always support the alvelous on both sides
and apply controlled force during extractions.
MANAGEMENT: If the tooth is displaced into the lingual
spaces, it must be removed it otherwise acts as foreign body
and likely causes infection later.If the root fragment is small
and uninfective, it may be left behind.
Displacement of tooth into sub-mandibular space,
infratemporal space and oropharynx
13.NERVE INJURY
CAUSE: various branches of trigeminal nerves may be injuried during
extraction.
If the nerve is present in a bony canal such as the inferior alveolar nerve,
the nerve tends to regenerate more easily and sensation may return over a
period of time
A. The lingual nerve is usually injured during procedures
B.MENTAL NERVE : procedures done at the lower premolar region may
injure the mental nerve
C.INFERIOR ALVEOLAR NERVE:this nerve may be injured in cases where the lower molar root
lies closer or perforates the canal .

PREVENTION: Radiographs help to locate the position of IAN in relation to the teeth that are being
extracted. Incisions in the region of other nerves should be made with care to prevent injury
MANAGEMENT: if IAN is injured, since the nerve lies with in a bony canal it usually tends to
regenerate. Patient should be informed to check for improvement in the sensation over the region
supplied by the nerve.


C.INFERIOR ALVEOLAR NERVE:this nerve may be injured in cases where
the lower molar root lies closer or perforates the canal .

PREVENTION: Radiographs help to locate the position of IAN in relation to
the teeth that are being extracted. Incisions in the region of other nerves should
be made with care to prevent injury
MANAGEMENT: if IAN is injured, since the nerve lies with in a bony canal
it usually tends to regenerate. Patient should be informed to check for
improvement in the sensation over the region supplied by the nerve.


14.HEMORRAGE:
CAUSE: some amount of bleeding is normal after an
extraction this usually stops by application of pressure in
a couple of minutes. Excessive bleeding is seen in
hypertensives and in cases where a vessels has be severed

PREVENTION: if a patient is hypertensive selective
procedures should be done only if his blood pressure is
controlled
patients on anticoagulants should be investigated properly
on a physicians opinion taken prior to extraction
15.DISLOCATION OF A JAW
IT is an another rare complication.
Types
Primary
bleeding
Reactionary
bleeding
Secondary
bleeding
Primary bleeding when complete hemostasis is not
achieved at the completion of the surgery.
Reactionary bleeding occurs within the 48hrs of the
surgery, this is due to local rise in B.P. Causing opening
up of small divided vessels which were not bleeding at the
end of surgery.
Secondary bleeding-this occurs 7 days post-operatively,
usually due to infection destroying the clot.
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PREVENTION AND
CONTROL BY LOCAL
HAEMOSTATIC METHODS
Collagen plug

Microfibrillar collagen

Regenerated oxidized cellulose

Collagen tape

Absorbable gelatin sponge

It is usually present after any surgical procedure.

It is important to keep the patient comfortable by
prescribing anti-inflammatory analgesics.
A normal extraction procedure is usually not associated with swelling.
But trans-alveolar procedure involving bone cutting will cause some amount of
swelling.
Swelling could be due to 3 reasons :
edema
hematoma
infection

Management: antibiotics and placing ice over the swelling.
Also known as alveolar osteitis.
It starts with moderate to severe pain on the 3
rd
to 4
th

post-operative day.
There is a loss of blood clot in the socket & socket
appears empty.
Severe inflammation of the soft tissue around the
wound.
Throbbing pain which may radiate to ear, bad odour
& accompanying bad taste in the mouth.
Etiology
Due to high levels of fibrinolytic activity around the
extraction socket resulting in lysis of the blood clot &
thus exposure of the bone.
bone is very painful on probing.
Management
relieving pain & socket is gently irrigated * an
abtundant is placed.

Infection from surgical site may spread to adjacent
facial spaces resulting in space infection.
There is usually associated trismus with the
involvement of the masticatory spaces due to spasm
of the muscles involved.
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Patient should be adviced to
1.Firmly bite on gauze piece placed on the extraction socket
for a minimum of half an hour after the extraction

2.Not to rinse his mouth vigourously for the next 24 hrs.

3. To avoid any hot food for the next 24hrs
.
4. Advised soft diet on the day of extraction

5. Not to suck from the straw on the day of extraction

6. Warm saline rinses and gentle brushing should be
adviced from the next day
7. Anti inflammatory analgesics should be prescribed.

8. Inspite of all these precautions if there is profuse
bleeding from the socket the patient should be adviced
to return to the dentist.
Contemporary oral and maxillofacial surgery- Peterson, Ellis, Hupp
Oral and maxillofacial surgery- volume 2, Daniel
Chitra chakravarthy

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