Oral surgery lec # 5

29/3/2009

‫بسم الله الرحمن الرحيم‬

Hello everybody 

this z my first lecture and i did my best to make it ( r5eesa w kwayseh w

bnt nas ) ,, the record was too long ( 80 mnts ), the doctor skipped many
slides and unfortunately i don’t have copy of them ,, so read the handout
beside the lecture .

lets begin and plz try to enjoy ....

prevention and management of surgical

complications

our lecture today talks about the most common complications occurring
during or after oral surgical procedures , the later we call them
postoperative complications .

complications which might occur during the surgical procedure could be

related to the soft tissue at the site of extraction , to the teeth being
extracted , to the anatomical structures adjacent to the site of surgery
like nerves , or to the bone .

Complications are unfortunate things that we can’t prevent their happening

even with perfect planning and excellent surgical technique, so the most
important issue is :

1. To know how to manage them if these complications occurred.

2. dentists must perform surgery that is within their limitations and
capabilities , so the dentist must keep in mind that referral to a

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specialist is an option which always should be exercised if the planned

surgery is beyond the dentist own skill level .

Prevention of complications:
The best and easiest way to manage complications is to prevent them from
happening by a thorough of a preoperative assessment and comprehensive
treatment plan .

– What do we mean by preoperative assessment ???

1. Thorough review of the patient medical history .
2. Full examination ( extra and intra orally )
3. Investigations ( radiographs and blood investigation )

One of the primary ways to prevent complications is by obtaining adequate

radiographs and carefully reviewing them .... these radiographs must
include the entire area of surgery , including the apices of the roots of
the teeth to be extracted , in addition to the local and the regional
anatomical structures such as adjacent parts of maxillary sinus and the
inferior alveolar canal .

4. Treatment plan .
5. Then you go with your treatment .

After doing all these steps perfectly , if complications occurred you will be
able to manage them .

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 , attempts to do surgery with inadequate access or the use of
excessive or uncontrolled force .

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1. Tear of a mucosal flap

When you perform a surgery you need to raise a flap with adequate size
to have a good visual access for the site of surgery .

Tearing of the mucosal flap usually results from an inadequately sized flap,
which is then forcibly retracted beyond the ability of the tissue to stretch
as the surgeon tries to gain needed surgical access .

2. Puncture wound of the soft tissue

This injury is the result of using uncontrolled force and is best prevented
by the use of controlled force , with special attention given to using finger
rests or support from the opposite hand in anticipation of slippage ..

For example while you are using the elevator and this elevator suddenly
slipped , it will go into the tissues and puncture them .

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Pic in doc slides : injury in the palate as a result of elevator

slipping .

3. Stretch or abrasion injury

Abrasions or burns of the lips , corners of the mouth , or flaps usually
result from the rotating shank of the bur on the soft tissue or on a metal
retractor in contact with soft tissue ..

Ex : while you are removing bone in surgical removal of teeth , if you are
not careful enough , the hand piece will injure the mucosa or the lip and
burn it .

Pic : in this pic you see burn to the lip , so you need to focus in
your surgical field .

At the same time the assistant should be aware of the location of the
shank of the bur in relation to the cheek and lips .

– But if this happened ... other than keeping the area clean with
regular oral rinsing , you should advice the patient to apply
antibiotics, ointments and Vaseline ..
• Antibiotics : to protect the patient from getting infected
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• Vaseline : to provide a protective coating to prevent any

material from coming in contact in this .
• Ointment : the patient should keep the area moist with
the ointment during the entire healing period to prevent
scar formation and delayed healing , as well as to keep
the area reasonably comfortable but the patient must
keep the ointment only on the abraded area and not
spread onto intact skin because it is likely to cause a
rash .

4. Subcutaneous or submucosal emphysema

During bone removal , while you are using the high speed drill which is with
compressed air , this air may go into the tissue spaces . this might be
dangerous and sometimes it might be fatal , the patient may die because
the air from the high speed we are using to remove the bone or divide the
tooth might go into tissue spaces in the neck and compress the airways .

So you need to be careful about this , but most of the time small amount
of air may go to the soft tissues and if you press on them or palpate
them, you will feel crackling sound ( FAGAGEE3 ) .

Management : usually we do nothing , they are self limiting and usually

disappears in few days .. ( but we should be aware of them ) .

5. Broken instruments in tissue

– Cause : use of excessive force and repeated use of instruments .
– Treatment : radiographic localization and removal .

Proper instruments should be used during the procedure , so you should

avoid poor quality or old instruments ( they must be still functioning )
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Pic ( radiograph, in doc slides ) : broken instruments like fissure

burs or round burs .

You should be careful to assess if you can remove them by yourself or

refer the patient to a specialist .

Problems with a tooth being extracted:

1.Root fracture
The most common problem associated with the tooth being extracted is
fracture of its root . long , curved , divergent roots that lie in dense bone
are the most likely to be fractured .

– Causes :
1. Heavily restored tooth
2. Improper technique
3. Ankylosed root 4. Hocked curved root

In the radiograph you can see if the tooth is ankylosed , has hocked roots
or divergent roots , then you can do surgery , divide them or remove bone
to remove them easily without complications .

1.Tooth/root displacement into maxillary

sinus
Pic( in doc slides) : first molar in the maxillary sinus ...

The amount of bone separating the root from the maxillary sinus is very
small and it is easy to make communication between the sinus and the oral
cavity during extraction , so you should be ready if this happened .

Communication between the the sinus and the oral cavity may occur (as the
doctor said ) due to 2 reasons :

1) The absence of bone because of

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1. Resorbing due to infection

2. There is no bone in the floor of the
sinus , its just soft tissue separating
the root from the sinus .

1) Maxillary sinus pneumatization ( the alveolar process become occupied

by maxillary sinus ) so even with simple extraction this thin bone will
fracture with the root and lead to communication with the sinus .

– Pneumatization may happen without extraction , and it is not a normal

process .
– If a root fragment or all the entire tooth is displaced into the
maxillary sinus , what shall we do ?
a) If it is small and noninfected , leave it because u need an
extensive surgical procedures to remove it .

The small and noninfected root tip can be left in place because it is unlikely to cause
any troublesome sequelae . additional surgery in this situation causes more patient
morbidity than leaving the root tip in the sinus . if the root tip is left in the sinus ,
the patient must be informed and given proper follow up instructions for regular
monitoring of the root and the sinus and you should give him the special sinus
precautions ( antibiotics , nasal decongestion , analgesics ) .

b) If the root tip is large and infected , it should be removed . and

if the whole root is infected you should refer the patient to a
maxillofacial surgeon .

The usual method for removal is CALDWELL-LUC approach into the maxillary
sinus in the canine fossa region and then removal of the tooth .

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– The tooth root that is most commonly displaced into unfavourable

anatomic spaces is the maxillary molar root . if a fractured root of a
maxillary molar is being removed with a straight elevator being used
with excessive apical pressure , the root can be displaced into the
maxillary sinus .

Note : for implants we need adequate width and height of bone , if this
isn’t available we do bone grafting to provide adequate adequate width and
height .

– We said that the tooth can be displaced into the maxillary sinus ,
and sometimes while you are extracting a maxillary third molar you
might displace it into the infratemporal fossa .
– Behind the maxillary tuborosity is the lateral ptregoid plate and
lateral to it is the ramus so if u displace the tooth in this area and
the ramus is in the other side , you
might affect the mouth opening of the
ramus so you need to remove it , and this pic from the book you
,, I know it’s not clear
have to be careful .
at all bs bemshe 7alha
– If the displacement happen while you are

doing the extraction , if you have
good visibility and access , you can (B) tooth in the try
maxillary sinus is the
to remove the tooth one attempt , if you
maxillary third
can’t do that at one attempt close and
molar .. 8
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refer him , because the tooth may displaced further back and
removing it will be extremely difficult .
– When u refer the patient to a surgeon , if the pt doesn’t have any
problems and the tooth is not infected so why we do anything . bt if
the tooth is interfering with mouth movement and mouth opening so
the surgeon should open and remove it .
– In the maxilla the teeth maybe displaced in the sinus or in the infra
temporal fossa .
– while in the mandible the bone ( the apical bone ) specially on the
lingual side related to the molars is thin ,, so if you apply an elevator
and make a pressure you might displace the root or the tooth into the
submandibular area , so to avoid this you need to avoid the apical
pressure because you are going to push them against the thin lingual
bone which can be fractured and the teeth will go into the
submandibular space ,,,,
if this happened , you can place your thumb lingually and try to push
the tooth , if you can feel it through the socket so back it again ,, if
you can’t , refer him to a maxillofacial surgeon ( need to reflect a
flap lingually to be able to remove the tooth ) .

3. Tooth lost into the oropharynx

The teeth may be swallowed or aspirated , if the patient swallowed a
tooth and it went to the GIT , usually he will pass it 3-4 days later , but
we need to make sure that the tooth is in the GIT by taking abdominal x-
rays ,, so swallowing isn’t a serious problem .

But the problem is when the patient aspirated the tooth ... the tooth will
go to the airways and close them completely or partially ,, then the pt will
suffer from cyanosis , cough and difficulty in breathing ,, also he may
die !!!!!
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So if the patient aspirated a tooth , you must be sure that the airways
are potent , then you should take chest x-rays .

Sometimes we do endoscopy or bronchoscopy ( enter a scope inside the

bronchus and try and try to remove the foreign body )

Removal of the aspirated body is an emergency case which must be done in

the hospital .

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.

Injury is often due to use of bur to

if first molar is to be
remove bone or divide a tooth for
removed ,, care must be
removal . the surgeon should take care
taken not to fracture
to avoid getting too close to adjacent amalgam in the second
teeth when surgically removing a tooth . premolar by elevator or
this usually requires the surgeon to keep forceps ...
some of the focus on structures adjacent
to the site of surgery .

1. fracture or dislodgment of an adjacent

restoration
While you are extracting a tooth you may damage the filling in the tooth
adjacent to it , so you should be careful .

And you should warn the patient preoperatively about the possibility of
fracturing the restoration during the extraction .

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If this occurred the tooth should be smoothed or restored as necessary to

keep the patient comfortable until a permanent restoration can be
constructed .

2. luxation of an adjacent tooth

- inappropriate use of the extraction instruments may luxate an adjacent
tooth , so sometimes during extraction of a tooth , as a result of applying
pressure on the adjacent tooth , it may be luxated ( like when you are
using an elevator )

- it could be also as a result of crowding , so if the tooth to be

extracted is crowded and has overlapping adjacent teeth , as it commonly
seen in the mandibular incisor region , a thin , narrow forceps may be
useful for the extraction ..... forceps with broader beaks should be
avoided because they will cause injury and luxation of adjacent teeth .

- management : if an adjacent tooth is significantly luxated or partially

avulsed , the treatment goal is to reposition the tooth into its appropriate
position and stabilize it so that adequate healing occurs .

3. extraction of the wrong tooth

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- causes : 1) inadequate attention to the preoperative assessment .

2) a common reason for removing the wrong tooth is that a

dentist removes a tooth for another dentist , thus the

wrong tooth is sometimes extracted when the dentist is

asked to remove teeth for orthodontic purposes , specially

in pts with mixed dentition stages .

– management : if the wrong tooth is extracted , and the surgeon

realizes that immediately , the tooth should be replaced quickly into
the tooth socket . if the extraction is for orthodontic purposes , the
surgeon should contact the orthodontist immediately and discuss
whether the tooth that was removed can substitute for the tooth
that should have been removed ,, and if the orthodontist believes
that the original tooth must be removed , the correct extraction
should be deferred for 4 or 5 weeks until the wrongfully extracted
tooth regain its attachment to the alveolar process .
– The surgeon should not extract the contralateral tooth until a
definite alternative treatment plan is made.
– When the wrong tooth is extracted, it is important to inform the pt
and any other dentist involved with the pt care.
– The point is not YEEEH we did a mistake, it is how to manage this
mistake.

Injuries to the osseous structures :

1. Fracture to the buccal plate

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The most common sites where bone fracture may occur are the buccal
cortical plate in canine region, molars region and lower anterior teeth
region.

– The bone is more prone to fracture:

a. in old people
b. And if it is thick..... While doing extraction you expand the
socket, if the bone is thick so it is not elastic then you can’t
expand the socket and u may fracture the bone.

note : infiltration can work in thick bone .

– While you extracting the upper first molar and you felt that the
buccal plate is moving, what you should do ?

1) If the bone is still attached to the soft tissues , try to separate

the bone and soft tissue from the root then you can remove the
tooth easily ..
2) If you can’t do that, stop the extraction and ask the pt to come
back after six weeks.. Then you do the extraction by surgical
techniques (more controlled bone removal, instead of removing the
whole buccal plate , we remove only the bone required to remove the
tooth ) .

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– but if you extract the tooth with large amount of bone so here u
can’t replace it again , just do smoothening for the sharp edges of
the bone then suturing , and the most important thing is to inform
the patient .

Pic: piece of bone was removed with the tooth instead of

removing the tooth alone 

2. Fracture of the maxillary tuberosity

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Pic: maxillary tuberosity was removed with the tooth.

– During extraction if you noticed that the bone is moving , try to

separate the bone and the soft tissue from the tooth then extract
it, or you start surgical removal , or dismiss the patient and ask him
to come after 5-6 weeks to remove the tooth surgically .
– Soooooooooo it is very important to keep the bone attached to the
soft tissue, WHY !!! to keep it supplied with blood ..
– If you remove the tuberosity with the bone , you have nothing to do
except irrigation and suturing .

3.fractures of the jaws :

Patients with a weak jawbone structure (e.g. older women with
osteoporosis) may have a risk of jaw fracture. Even if the actual tooth
extraction procedure is performed smoothly without any problems, there
are cases of complications during the healing process.

- Causes: excessive pressure during extraction and thin bone that slight
pressure can break it .

- Management: TAJBEEER .

Injuries to the adjacent structures :

1. injury to regional nerves :
A mistake during an extraction of a tooth from the lower jaw may damage
the inferior alveolar nerve. Numbness in the lower lip and chin are common
symptoms of a damaged nerve. The nerve will heal in a few weeks up to
some months depending on the extend of the damage. In rare cases, the
nerve is unable to heal completely, leaving the patient with a permanent
numbness.

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2. Injury to the temporomandibular joint

( The doctor didn’t talk about them at all  )

Foreign bodies :
– Foreign bodies : tooth , root , detached fillings may be either
swallowed or inhaled .
– Inhaled foreign bodies which may obstruct the airways can cause
rapidly developing cyanosis and exaggerated respiratory effort ..
immediate steps must be taken to restore potency of the airways .
– Management :
1) ask the pt to cough , because cough action forces the foreign body
to come out ,,, so ask him to cough and split on the floor to be sure
that the FB came out .
2) If this failed hit him on his back .
3) And again if this failed .. Stand behind the pt and put ur hands on
each other below the sternum of the pt then push 3-4 times ( this is
called HEIMLICH MANUVER ) .
4) Failed again .. lie the pt on his abdomen and put ur hands below
his sternum and push ..
5) Failed then la 7wl wala qewata ela belah w ma elu ‘3er rbna 

Here the doctor skipped many slides  then he started saying : we need to
bypass the area of obstruction by something we called crichothyrotomy .

We have membrane between cricoid and thyroid cartilage called the

cricothyroid membrane, and the cricoid is the only complete tracheal ring .

Ex : the laryngeal prominent of the thyroid cartilage ( adam’s apple ) , it

is the area of thyroid cartilage , above it we have hyoid bone and below it
we have the cricoid cartilage and between thyroid and cricoid we have
membrane ,, so if u put ur fingers ( the little finger on the hyoid bone and

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other two fingers below adam’s apple , in the area in between we enter
anything to open the area and allow the passage of air ...

Tooth extraction complications after the

operation:
Possible tooth extraction complications after the operation include :

1. Dry socket:
A dry socket following a tooth extraction is a common complication in
about 5% of people who have a tooth extracted. The condition occurs when
a blood clot does not form normally in the tooth socket or the blood clot is
washed out or dissolved prematurely. In a dry socket situation, the
underlying bone and nerves are exposed to air and food, causing intense
pain and sometimes bad odor or taste. A dry socket needs to be treated
with a medicated dressing to stop the pain and help healing.

2. Infection:
The wound of the tooth extraction can be a doorway for bacteria causing
an infection, particularly in patients with a weakened immune system. If a
patient has a high risk of infection the dentist will generally prescribe
antibiotics before and after the extraction.

3. Excessive bleeding and/or swelling, redness or

fever.
If you have any of these symptoms, especially if they continue after the
first 24 hours, contact your dentist or oral surgeon for advice.

The postoperative complications were not mentioned by the

doctor 

Many slides were skipped here ,,

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And now EL7AMDOLELAH it is the end 

Bma enu dayel makan bl saf7a fa 5leena nktb km ta7eyeh ...

– My frndz whom i miss sooooo much ( Reem Qudeisat ,, Hala hajeer , Sahar
karasneh , Hanaa Marzooq and Yasmeen Asfoor ) .

– My best frndz :

Maram Bataiha ( o8eru 2na el mzkor a3lah , saken bl 3enwan eyah bltanazol 2dam el
df3a klha yalla 3eshe wel ba2e 3ndek  )

Ruba al tawara ( happy birthday ror w 3o2bal e 1000 ya rb ,, bs da5lek shu 25bar el
jorth !!!!! )

Zain smadi ( ma 7d fahem mwhebte el m2anteka ‘3erek ,, slamet 3yonek ya zozo )

Esraa Gozlan ( 2aaaah b3ed elayale wel 2yam mn sho2e eleak )

Rawan Rahhal ( 7awalt at3awad bs ma tele3 m3e shi  )

Mais Hatamleh ( bma enu el 7yat salaf dean w bma enek katabtele ehda2 fa jmeltek
3la 7alek ,, 3asal walla m3 enu bndal netna2ar )

– Ta7eyeh kman la kl group C w 5asatan C2 ( we r the best  )

– Finally .. for u dr. Baker Quteishat ( dayman 3ndak solafeh , alla
yjeeb 2a5er hl sawaleef 3la 5ear  w m3 enu ma nef3ni el endo
taba3ak  )

Tell me if there z any mistake

Heba Jaradat

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