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‫ي القيوم‬

ُ ‫بسم ال الح‬
Surgery lec #7 5.4.09

PREVENTION & MANAGEMENT OF SURGICAL


COMPLICATIONS

.Today we will continue what we started last lecture

:Nerve Injuries
What are the injuries? How do they occur? How do we
?treat them

The nerves we encounter in the oral cavity mainly are the


Inferior dental nerve, lingual nerve, mental nerve,
.(infraorbital nerve (not in the oral cavity

:Trauma to nerves can result in


.Anesthesia = Complete loss of sensation .1
.Hypesthesia = decrease in sensation .2
Paresthesia =A stage in nerve recovery following injury .3
so the patient may feel some burning sensation or tingling
.or numbness
Dysesthesia = unpleasant sensation to normal stimulus .4
.like burning sensation when touched

We have 3 Types of Injuries to the nerve according to


:Seddon's classification
Neuropraxia = hitting or putting pressure on the nerve, .1
.the nerve will recover it has the most favorable prognosis
Axonotmesis = degeneration of the nerve axons but the .2
nerve is intact. Most probably the nerve that sustains this
.injury will recover
Neurotmesis =it is the worst type of nerve injury which .3
is cutting of the nerve so the chances of recovery are very
.poor

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Ex: when the mental nerve is very superficial and when
you raise a flap and you didn’t observe the nerve you
.might easily damage it
Ex: when raising a flap and its not adequate, so you start
pulling and tearing the flap causing injury to the nerve. We
need to raise an adequate sized flap to decrease pressure
.on the nerve
Ex: Flap retractors used during surgical procedures also
.may cause tearing

On the X-rays if you want to remove the impacted lower


3rd molar or roots, they have a close relationship with the
mental nerve or the ID nerve. Unless you are careful
enough and you plan your procedure properly it is easy to
.damage these nerves

When you are sectioning a lower 3rd molar, the drill or bur
will sometimes go deeper into the canal and cut the ID
nerve in a similar fashion and if you go lingually the lingual
.nerve will also get injured

See the curved root & the root is displaced to the ID canal
leading to injury of the ID canal and the removal of this
.tooth will also lead to injury of the ID nerve

This tooth is associated with periapical pathology so if you


try to clean or debride the periapical pathology you might
.injure the nerve so you have to be careful

If a root is displaced into a canal its better to extract the


remaining root to remove the pressure on the nerve. We
prescribe an analgesic and sometimes vitamin B12 to aid
.in regeneration of the nerve

MANAGEMENT OF BLEEDING FOLLOWING ORAL


:SURGERY

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Some patients might bleed during the oral surgery and ..
some might bleed postoperatively when they leave the
.clinic

Controlling bleeding in the oral cavity can be challenging ..


because the oral cavity has a very rich blood supply both
to the soft tissue and bone so whatever you do it is easy
.to provoke bleeding

When doing extraction we have an open wound both in..


.soft tissue and the bone causing more oozing of blood

Applying pressure on the area of surgery is not easy and..


plus some patients after leaving the clinic remove the
gauze, start sucking the blood and play around the wound
with their tongue leading to loss of the blood clot which is
essential for the formation of granulation tissue and
.healing of the socket which if lost causes delayed healing

Some patients are stubborn and don’t listen to your..


instruction and do whatever is in his mind which leads to
.delayed healing

In the oral cavity we have saliva which contains enzymes,..


these enzymes might lyse the blood clot and enhance
.bleeding

:TYPES OF BLEEDING

.REACTIONARY BLEEDING: 1
Is the bleeding that occurs in the first 24hrs following
surgery. The factors that provoke bleeding in these
:patients are
Exercise..
Sometimes local anesthesia which contains a..
vasoconstrictor which helps in the control of bleeding but
the effect is minimal
Application of heat to the wound..
Mechanically with the tongue..
Sometimes when patients are under general anesthesia ..
the anesthetist lower the blood pressure of the patient to

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control the bleeding. Once the patient is awake and during
recovery the blood pressure will return to normal and
.leads to bleeding
Coughing..
.Smoking because of the negative pressure..

:SECONDARY HEMORRHAGE .2
Bleeding that happens after 10 days from the surgery
.usually due to infection and sepsis at the site of surgery

?How do we manage patients who show bleeding


.We should manage them similar to any patient
Taking History, Examination , Investigations and
.Treatment

:Management depends on the patient

We have a group of patients with bleeding tendencies


like: Congenital: Hemophilia factor 8 or 9, Liver problems,
Von Willebrand's disease, platelet disorders,
thrombocytopenia, disorders in the production of blood
.cells where the platelet production is decreased
.Acquired: patient who take anticoagulants like warfarin

We have Patients who have normal bleeding meaning


.their coagulation process is normal

How is the process of Hemostasis and How to control


?bleeding
During surgery if we have a blood vessel that was injured
?due to surgery what is the 1st thing to happen
Primary
Vasoconstrictor: decrease the amount of the wound .1
.decreasing the amount of blood reaching it
Platelet aggregation, the small wound will be closed by .2
.the platelets

:Secondary
Coagulation time: which are affected by thombin,
prothrombin, fibrin, collagen, extrinsic and intrinsic

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factors. We should know these and we will be asked about
.them

:Main methods to control bleeding


.Compression: Pressure on the wound .1
Suturing: we do a figure-eight over the socket and the .2
gauze is underneath, to give us pressure on the healing
.site
Ligation: bleeding can be from bone or can be from soft .3
tissue, if we can identify the bleeding vessel then using
artery forceps (mosquito) we can hold the bleeding vessel
and tie it so it is closed. The vessel was fine but during
.surgery it was cut so we tie both ends of the vessel
Electrocoagulation: which is by heat (burning) using .4
..bipolar, unipolar or dithermia
Hemostatic agents: They help in controlling bleeding. .5
Their goal is to support the blood clot and it may contain
collagen, prothrombin to help the clotting mechanisms,
some of them not only support the clot but enhance the
.coagulation process

When performing the surgery the best way to prevent


bleeding is not to cause bleeding. How we can not cause
?bleeding
.Be gentle on tissues. 1
Clean Incisions 3. 2
.Plan your surgery properly and avoid blood vessels in the
.area of the surgery or ligate them

When performing the surgery and there is bleeding, you


examine the site of the surgery. The bleeding can either
be from the soft tissue or the bone, if in soft tissue we
.ligate it or burn it, then ask the patient to bite on a gauze
Sometimes the bleeding can be from bone and in the bone
there are foramens containing blood vessels, if you cut or
injure blood vessel going into bone then you will end up in
bleeding ex: when doing surgery for lower 3rd molar there
is an accessory blood supply to the area which varies
anatomically in different patients. When you reflect the

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flap you will injure the blood vessel and you will have
.bleeding

?What to do if bleeding from boneً


We crush the bony foramen which will occlude the
.(bleeding site using the artery forceps (mosquito

For bleeding of bone we can also use bone wax which


occludes the area and has a hemostatic effect when
performing the surgery, examine the site and if it is not
clear to you that bleeding is coming from soft tissue or
bone and the bleeding is still continuing so what do we do?
We can use a material that can help in controlling bleeding
.Ex: Pack the socket with hemostatic material

We have different Hemostatic materials and the aim of


these materials is to help support the clot at the site of
injury. Some may contain factors that help in the
coagulation process and they might place pressure on the
.site of bleeding

Shown in the slides an extraction socket and we packed it


with hemostatic material. This is one of the measures used
when the bleeding is not from the soft tissue and no
.obvious bleeding from bone

?What are the materials we might use


Collagen, Oxidized regenerated cellulose, Gelatin sponge
.etc

How do they differ? Some of them are easy to use, some


.of them can be packed easily and some are expensive

1) Gelatin sponge (ex: Gelform): is friable meaning it


breaks down easily, is not packed easily in the socket, but
is the cheapest.

2) Oxidized regenerated cellulose (ex:Surgicel): easy to


pack so its better than gelform so we can apply pressure
and pack it, but it is associated with increased percentage

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of delayed healing.

3) We can also add prothrombin on gauze and use it to


pack the socket by adding pressure.

4) Collagen is present in different types, but they are the


most expensive.

If we extracted a tooth for a patient then after he leaves


he calls saying that 'I am bleeding', so what do you do?

1. Rinse slightly with cold water which has a constrictor-


like effect.
2. Ask the patient to bite on a gauze for 30 minutes.

Some people say that you can put a tea bag after soaking
it in water and bite on it for 30 min, because in tea we
have tannic acid which will help in controlling the bleeding,
but the doctor does not recommend this because it is not
hygienic and it is not proven clinically.

If the bleeding persists call the patient to the clinic, if the


patient's family comes with him/her then separate the
family from the patient.
We need to identify the source of bleeding, examine the
patient with adequate light and access for vision of the
area, use suction to suck excess blood clot to see the
bleeding whether from soft tissue or bone.
Simply bite on the gauze and reassure him and calm him
down. Ask him to wait for 30 min, then we can use
suturing or hemostatic materials if bleeding did not stop.

Sometimes we use impression compound to apply


pressure on the gauze when the patient bites on it.

Don't dismiss the patient until bleeding is controlled, ask


him/her to walk around the clinic then you check the
hemostasis. Once the hemostasis is secured then
discharge the patient and give him the same instructions
you gave him before postoperatively.

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Despite these measures if the bleeding can not be
controlled then the patient should be referred to a hospital
for further investigations. Sometimes we get patients who
bleed for a long time, ex: Bleeding for 2 weeks
(continuous oozing)!!

After 2 weeks if bleeding still persists we start taking very


specific investigations, and we might find one of the rare
blood anomalies.

DRY SOCKET
Localized osteitis meaning inflammation of the bone or of
the socket. Usually it's painful when you are examining the
patient there is no blood clot only bare bone. Their
incidences are 3% of all extractions and between 14-37%
of lower 3rd molar extractions are complicated or will have
dry socket.
Clinically the patient on the 2nd or 3rd day after the
extraction they start to complain of pain, this pain is
continuous and it is moderate to severe throbbing pain,
sometimes radiating to the ear, and also patient might
complain of bad taste and bad odor. However, the etiology
is not known!
But we have predisposing factors like infections,
smoking, excessive physical force during extractions, and
vasoconstrictor of local anesthesia.
In certain patients they have increased fibrinolytic activity,
also certain type of bacteria will have high activity might
cause dry socket. Pregnant women have increased risk of
dry socket but no one knows why!!

What is our aim?


* To reduce pain
* Speeding of resolution of the condition

Management of dry socket: it is different in different


areas but basically you irrigate the area with normal saline
and/or Chlorhexidine.

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Dislocation of TMJ
When do we have dislocation of the TMJ?
-Trauma
-Difficult extraction
-Prolonged Endo-treatment or prolonged surgical
treatment.

Treatment of TMJ dislocation

Stand infront of the patient ,place thumbs on the


external oblique ridge intraorally not on the occlusal
surface of teeth because the patient might bite on your
fingers, while the other fingers on the angle of the
mandible pushing downward with the thumbs and with
fingers push backward and upward. When you put
pressure downward the condyles goes down and you push
it back, then ask him not to open his/her mouth widely or
yawn for a couple of days.
Condyle comes out from the glenoid fossa, usually the
articular eminence prevents this from happening but in
dislocation the condyle passes the eminence, and it is very
painful.

TRISMUS
Limited mouth opening due to muscle spasm.
Can be caused by many ID injections given, excessive
force, infection etc.

Treatment of Trismus
If there is a cause we have to identify it.
Tell the patient to apply heat on the affected area.
Rinse with warm water and salt, and perform some
exercise to increase mouth opening (physiotherapy).

Hematoma - swelling and collection of blood.

Ecchymosis - breakdown of the components of blood


(hemoglobin and bilirubin) which appears as a yellowish
appearance on the skin.

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Infection in the wound
Is a complication which can be caused if used
instruments are not sterile, or if the procedure we did is
not correct or if the patient has a systemic disease etc.
We treat the infection by Cleaning and debriding the area
infected.

If patient you were treating suddenly became yellow and


couldn't breath what will you do?
This is called fainting or losing consciousness.
The cause may include - Endocrine cause ex:diabetic
patient, Hypotension, stress, cardiac problems mainly
vasovagal attack, stroke, asthmatic attack, myocardial
infarction which is a more serious cause, angina, severe
coughing, neurological conditions such as epilepsy.

MOST COMMON cause of collapse is vasovagal attack- in


which there's transient loss of consciousness because of
decreased blood flow to the brain, it is mediated to an
autonomic reflex leading to vasodilation of the blood
vessel in the abdomen and muscles, when the blood
vessels in the abdomen and muscle dilate the blood will
pool there so the blood in the heart will decrease and the
oxygenated blood from the heart to the brain will
decrease, no blood is going back to the heart to be
pumped.

If your patient had a vasovagal attack what do we do?


* Stop treatment
* Remove things in the mouth like gauze, filling materials,
files.
* Put him in supine position.
You may also put him on his side to avoid aspiration.
Reassure the patient and most of the times the patient will
recover.

If the patient doesn't recover, we suspect MI or angina


then we need to manage him with GTN (nitroglycerin),
oxygen.

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MI - medical emergency [patients need to go to the
hospital.]

If the patient is diabetic which is more common? hyper or


hypo? Hypoglycemic is more common. So in either case, if
we don't know, we just give the patient sugar because
even if his sugar level was 400 then it became 450 it's not
a big deal.
If the patient is hypoglycemic and sugar was given then
the patient will recover.
‫تم بحمد ال‬
(Sana'a plz next time when you sit next to the record keep
your voice low)

Note: In addition to the lecture we have to read the


handouts because there are many things the dr. did not
mention in the lecture which are important…
Wishing you all the best in the coming exams...

I would like to take this opportunity to thank all of you for


your support and encouragement on the passing away of
my only aunt (May Allah have mercy on her soul) and for
sharing the pain with me and my family. For those who
are in my dorm especially Fatma Aliyan who stayed with
me the whole time, to those who came to my dorm, those
who called me, talked to me in the lectures or the clinics
and to those who wrote prayers on Al-yaqeen group, I am
very grateful and thankful ‫جزاكم ال خير‬. I realized that I have
another family around me... Thank you again for your
concern and care…

Your
Colleague
Lamiya
Hassan Ramadan

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