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Complications of Dentoalveolar Surgery

David L. Basi DMD, PhD

ORAL and MAXILLOFACIAL SURGERY UNIVERSITY of MINNESOTA

Overview

• Prevention • Patient management • Soft tissue injuries • Hard tissue injuries • Post-operative complications

Prevention

• Planning • Know your limitations • Know your patient/procedure

– medical status – radiographs

Injuries during surgery

Soft Tissue Injuries

• Flap tears/necrosis • Instrument slips/tears • Lip burns/abrasions

Complications of Dentoalveolar Surgery David L. Basi DMD, PhD ORAL and MAXILLOFACIAL SURGERY UNIVERSITY of MINNESOTA
Patient Management • No surprises – informed consent • Tell – communication Prevention of soft tissue
Patient Management • No surprises – informed consent • Tell – communication Prevention of soft tissue
Patient Management • No surprises – informed consent • Tell – communication
Patient Management
• No surprises
– informed consent
• Tell
– communication

Prevention of soft tissue injuries

Patient Management • No surprises – informed consent • Tell – communication Prevention of soft tissue
Patient Management • No surprises – informed consent • Tell – communication Prevention of soft tissue

Surgical Technique

• Flap Design

– Access for bone removal – Access for sectioning – Periodontal health – Avoid injury to vital structure

Flap Design

• Incisions

– Sharp blade of proper size and shape – Firm, continuous stroke – Avoid vital structures – Blade perpendicular to skin or mucosa – Placement/margin control

Flap Design

• Apex never wider than base • Parallel or convergent sides

• Length of flap should be less than twice the base axial blood supply in base

• Base of flap should not be twisted or stretched

Proper flap design

Proper flap design
Surgical Technique • Flap Design – Access for bone removal – Access for sectioning – Periodontal
Torn Flap
Torn Flap
Displaced or retained roots Retained Root • Rule: Uninfected root tips (< 2-3mm) left within the

Displaced or retained roots

Displaced or retained roots Retained Root • Rule: Uninfected root tips (< 2-3mm) left within the

Retained Root

• Rule: Uninfected root tips (< 2-3mm) left within the bone have minimal complications vs. destructive surgical removal

Tooth/Fragment in Sinus

• Careful inspection • Radiographs • Remove promptly if possible

Tooth/Fragment in Sinus

• Surgical approaches

– through the socket- not recommended – buccal, superior to the socket – Caldwell-Luc

• Consider buccal flap if > 5 mm opening

Management of Displaced Teeth and Tooth Fragments

Maxillary sinus:

• Obtain a periapical or panorex radiograph to determine position.

• Root tips should be removed.

Management of Displaced Teeth and Tooth Fragments

Maxillary sinus continued:

Attempts can be made to retrieve smaller root tips by placing the patient supine, irrigating the sinus, and suctioning with a flexible suction catheter.

A regimen of antibiotics, antihistamine, and nasal spray should be given.

For removal of roots with pathology or larger roots, the Caldwell-Luc approach should be used.

Management of Displaced Teeth and Tooth Fragments

If a root tip is left, the patient should be informed of the circumstances. Radiographs should be taken and document in the patient’s chart. Follow-up radiographs should be taken at 6 and 12 months.

Remember….management of Displaced Teeth and Tooth Fragments

Criteria for root tips that need removal include roots that have apical lesions on radiographs or those with visible pathology or infection.

Also

..

roots

that are mobile…

Root tips in sinus need to be removed.

Oral - Antral Communications

Oral Antral Communications

• Small perforations (2-4mm) at the apex of the socket will usually heal

• Nasal precautions should be reviewed with the patient.

• Smoking affects the healing process and increases the likelihood of an oral antral fistula forming.

Oral Antral Communications

• For moderate size perforations (more than 5mm), primary closure should be obtained, the easiest and most reliable time to perform a closure of an oral antral communication is at the time it occurs.

• Nasal precautions should be reviewed with the patient, systemic and topical nasal decongestants and antibiotics should be prescribed.

Oral Antral Communications

• If there is not sufficient tissue, buccal bone may need to be removed, or if the opening is large, a buccal flap may be necessary to produce a water tight closure.

• Consider using a nonresorbable suture

• In patients with no evidence of sinus disease, the antibiotic of choice is amoxicillin. If sinus disease is present, the antibiotic of choice is Augmentin.

Sinus Floor

Sinus Floor

Sinus Floor

Sinus Membrane

Sinus Membrane

Primary Closure

Primary Closure Sinus Precautions!

Sinus Precautions!

Care of the Mouth Following A-O Communication

• Sinus precautions include:

– No nose blowing, straw sucking, smoking – Nasal decongestants, antibiotics

Prevention

Plan surgery:

Simple vs surgical extraction

Evaluate Sinus Make a surgical plan: Simple extraction
Evaluate Sinus
Make a surgical plan:
Simple extraction

Look at the Radiograph!

Sinus floor

Look at the Radiograph! Sinus floor Increased risk for sinus expos u
Look at the Radiograph! Sinus floor Increased risk for sinus expos u

Increased risk for sinus exposu

Have a surgical plan

Have a surgical plan •Simple vs surgical •Section tooth •Flap design

•Simple vs surgical •Section tooth •Flap design

Surgical Technique

• Flap Design • Removal of Bone • Sectioning of Tooth • Elevation and Delivery • Wound Management

Prevention Plan surgery: Simple vs surgical extraction Evaluate Sinus Make a surgical plan: Simple extraction Look

Surgical Technique

• Sectioning of tooth

– Avoid excessive forces to bone and adjacent teeth

– Reduce bulk of crown – Split roots – Purchase points

Surgical Technique • Sectioning of tooth – Avoid excessive forces to bone and adjacent teeth –
Surgical Technique • Sectioning of tooth – Avoid excessive forces to bone and adjacent teeth –
Surgical Technique • Sectioning of tooth – Avoid excessive forces to bone and adjacent teeth –
Surgical Technique • Sectioning of tooth – Avoid excessive forces to bone and adjacent teeth –

Hard Tissue Injuries

• Buccal bone fracture • Tuberosity fracture • Consider surgical extraction

• Management depends on periosteal attachment

Fractures

Tuberosity fractures:

If fracture of the tuberosity occurs and the tooth is asymptomatic and without pathology, the extraction should be deferred, and the tuberosity should be immobilized with an arch bar for 6 weeks prior to attempting removal.

If the tuberosity is only slightly loose, discontinuation of the procedure may be the only treatment necessary.

Maxillary Tuberocity

Fractures Tuberosity fractures: • If fracture of the tuberosity occurs and the tooth is asymptomatic and

Fractures

Mandible fractures:

• Mandibular fractures are a recognized complication of third molar surgery and should be listed on routine consent forms.

• Predisposing conditions are: Mandibular atrophy, osteoporosis, increased age and pathology such as cysts, growths or tumor.

Intra-operative bleeding

Bleeding • History/family history • Medications – ASA – NSAIDS – Coumadin • Hypertension
Bleeding
• History/family history
• Medications
– ASA
– NSAIDS
– Coumadin
• Hypertension

Bleeding: Intraoral Factors

• Vascular

• Often open wound

Loss of clot

Bone Wax:

(Salicylic acid and Beeswax)

Bone Wax: (Salicylic acid and Beeswax) Mechanism of action: Mechanical blockage of small bone cannels

Mechanism of action:

Mechanical blockage of small bone cannels

Bleeding: Management

• Pressure/patience • Injection • Bleeding vessel • Local anesthetic • Hemostatic agent

Bleeding: Prevention

• Atraumatic technique • Curettage of granulation tissue

Hemostatic Agents

Gauze

Gauze And……

And……

Pressure, Pressure and more…. Pressure

Pressure, Pressure and more…. Pressure

Gelatin

Gelatin Mechanism of Action: Helps stabilize clot formation (Does not activate coagulation cascade or platelets

Mechanism of Action:

Helps stabilize clot formation

(Does not activate coagulation cascade or platelets

Suture

Suture

Microfibrillar Collagen

Microfibrillar Collagen Mechanism of Action: Activates platelet aggregation

Mechanism of Action:

Activates platelet aggregation

Collagen

Collagen Mechanism of Action: Activates platelet aggregation
Collagen Mechanism of Action: Activates platelet aggregation

Mechanism of Action:

Activates platelet aggregation

Oxidized Regenerated Cellulose

Oxidized Regenerated Cellulose Mechanism of Action: Helps stabilize clot formation (Does not activate coagulation cascade or

Mechanism of Action:

Helps stabilize clot formation

(Does not activate coagulation cascade or platelets

Bleeding: Hemostatic Agent

• Topical thrombin

– Stimulates fibrin formation – Cannot use with surgicel (deactivates)

• Anti-fibrinolytic agents

– aminocaproic acid (Amicar) – tranexamic acid

To help minimize PO complications…

Do not disturb the wound

Smoking, spitting, rinsing vigorously

Bleeding

Bite on gauze 20-30 mins

Swelling, Pain, Bruising

Ice pack, head elevation, pain medication

   

Postsurgical Sequelae

•Pain

Post-op complications

•Swelling

•Bleeding

•Infection

Impacted Teeth

• Incidence of complications 10%

• Predictable: Pain, Swelling, Bleeding, Trismus

• Common: Alveolar Osteitis, 6 to 12%

• Rare: Nerve injury, jaw fracture

Postsurgical Sequelae

• Most common sequelae: PAIN

– Determine which analgesic(s) and how many to prescribed:

Can last 3 to 5 days • Bone removal (?) •
Can last 3 to 5 days
• Bone removal (?)

– Strong consideration: Length of operation

Postsurgical Sequelae

• Infection

– Ranging from 1.7% to 2.7% – 50% occur 2 to 4 weeks post op – Local, subperiosteal abcess

Alveolar Osteitis

“Dry Socket”

• Clinical presentation

– increasing pain post-op day 3 to 5 – malodor – pain not relieved by class III narcotic – pain awakes at night – radiates to ear.

Alveolar Osteitis “Dry Socket” • Patients at risk – females on oral contraceptives – smokes –

Alveolar Osteitis

“Dry Socket”

• Patients at risk

– females on oral contraceptives – smokes – Length of procedure

Alveolar Osteitis

“Dry Socket”

• Factors which reduce incidence

– prophylactic antibiotics (?) – copious irrigation – preoperative chlorhexidine rinse (50%) – antibiotics in extraction site

• Risk vs. benefit

Post-Operative Bleeding

Post-Operative Bleeding Removal of maxillary teeth

Removal of maxillary teeth

PO day 1

PO day 1
Liver clots
Liver clots

No active bleeding….What do we do now???

Management of Postoperative Bleeding

• If contacted by a patient experiencing prolonged bleeding, review the patient’s medical history and medications. Give the patient explicit instructions to bite down on a gauze with continuous pressure for 45-60 minutes. If the patient complains of brisk bleeding, they should be evaluated in the emergency room or office immediately.

• If simple measures do not control the bleeding, surgical intervention is indicated.

Management of Postoperative Bleeding

• Inspect the surgical site. Good lighting and suction are essential.

• If the use of local anesthetic is required, utilize one that does not contain a vasoconstrictor (this may give you temporary control, but may hinder your ability to determine the source of bleeding).

Management of Postoperative Bleeding

• If sutures are present, they should be removed so the surgical site can be evaluated adequately.

• Determine if the bleeding is coming from hard or soft tissues. Soft tissue bleeding can often be controlled with direct pressure; if the source of bleeding is granulation tissue, it should be curetted.

Management of Postoperative Bleeding

• Bleeding from bone: If the bleeding is from a pinpoint area, the bone can be burnished. If the bleeding is more diffuse, a hemostatic adjunct should be packed into the socket and direct pressure applied.

If during a dental extraction massive hemorrhage occurs, such as a central venous lesion, the tooth should be placed back into the socket as an initial means of hemorrhage control.

AO communication…continued

Fistula Formation

• Causes

– most common iatrogenic

• Incidence

– 1/180- first molar – 1/280- second molar

• Fistula < 5 mm may close spontaneously

Management of Postoperative Bleeding • If contacted by a patient experiencing prolonged bleeding, review the patient’s
Cycle of Sinusitis • Mucosal edema • Stasis • Inflammation and Hyperplasia Mucociliary Clearance • Presence

Cycle of Sinusitis

• Mucosal edema • Stasis • Inflammation and Hyperplasia

Cycle of Sinusitis • Mucosal edema • Stasis • Inflammation and Hyperplasia

Mucociliary Clearance

• Presence of preordained pathways to the ostia • Coordinated beating of cilia • Bypasses windows in the maxillary walls • Scar can form a barrier

Fistula Closure

• Two layered closure when possible • Buccal flap • Palatal flap

– posteriorly based – anteriorly based

• Combination flaps • Alloplastic materials

Cycle of Sinusitis • Mucosal edema • Stasis • Inflammation and Hyperplasia Mucociliary Clearance • Presence
Cycle of Sinusitis • Mucosal edema • Stasis • Inflammation and Hyperplasia Mucociliary Clearance • Presence

Oral-Antral Fistulas:

Conclusions

• If oroantral fistulas are small they may heal spontaneously

• For persistent fistulas- control sinusitis, establish physiologic drainage

• Two layer closure when possible

Nerve Injury
Nerve Injury
Oral-Antral Fistulas: Conclusions • If oroantral fistulas are small they may heal spontaneously • For persistent

Nerves at Risk in Dentistry

3rd division of CN V

– Inferior alveolar nerve – Lingual nerve – Mental nerve

Other nerves at risk in dentistry

• Incisive nerve • Nasopalatine nerve • Buccal nerve • Greater palatine nerve

Nerve Injury

• Inferior alveolar nerve - 3% accepted incidence reported

• Paraesthesia to anesthesia -transient vs. permanent • Most common: MA or Vertical impaction

Nerve Injury

• Lingual nerve with soft tissue reflection -3% to 11.5% reported

Seddon Classification of Nerve Injury • Neuropraxia • Axonotmesis • Neurotmesis
Seddon Classification of
Nerve Injury
• Neuropraxia
• Axonotmesis
• Neurotmesis

Descriptive Terms for Pain Response

Allodynia

– Pain due to stimulus which normally does not cause pain

Hyperesthesia

– Increased sensitivity to stimulus

Dysesthesia

– Unpleasant abnormal sensation

Anesthesia

– Absence of pain in response to stimulus that normally causes pain

Procedures with Risk

• Implants • Apical surgery • Periodontal surgical procedures

Procedures with Risk

• Local anesthetic injection • Flap elevation • Biopsy of lower lip or vestibular region

Procedures with Risk

• Surgical removal of mandibular third molars

– inferior alveolar – lingual – buccal

Conventional Sensory Tests

• Map affected area • Cold/warm • Von Frey hairs/blunt

Conventional Sensory Tests

• Brush stroke direction • Two point discrimination • Needle-sharp • Sensory evoked potentials

Conventional Sensory Tests • Map affected area • Cold/warm • Von Frey hairs/blunt Conventional Sensory Tests
Conventional Sensory Tests • Map affected area • Cold/warm • Von Frey hairs/blunt Conventional Sensory Tests

Indications for Nerve Repair

Indications for Nerve Repair

Nerve Repair

• Refer to specialist that treats nerve injuries ASAP

Repair of IAN Injuries

• Nerve exploration and decompression • Neurolysis • Direct neurorrhaphy • Interpositional nerve graft • Nerve transfer

Repair of IAN Injuries • Nerve exploration and decompression • Neurolysis • Direct neurorrhaphy • Interpositional
Repair of IAN Injuries • Nerve exploration and decompression • Neurolysis • Direct neurorrhaphy • Interpositional
Extraction socket Vicryl mesh/Lingual Nerve
Extraction
socket
Vicryl mesh/Lingual
Nerve
Antibiotics
Antibiotics

Prevention of Bacterial Endocarditis (High risk)

• Prosthetic cardiac valves • Previous bacterial endocarditis

• Complex cyanotic congenital heart disease

• Surgically constructed systemic pulmonary shunts or conduits

Moderate-risk category

• congenital cardiac malformations

• Acquired valve dysfunction (eg, rheumatic heart disease)

• Hypertrophic cardiomyopathy

• Mitral valve prolapse with valvar regurgitation and/or thickened leaflets

Dental Procedures (Endocarditis Prophylaxis recommended)

Dental extractions Periodontal procedures including surgery, scaling and root planning, probing, and recall maintenance

Dental implant placement and reimplantation of

avulsed teeth

Endodontic (root canal) instrumentation or surgery only beyond the apex

Subgingival placement of antibiotic fibers or strips

Initial placement of orthodontic bands but not brackets

Intraligamentary local anesthetic injections Prophylactic cleaning of teeth or implants where bleeding is anticipated

 

Endocarditis prophylaxis not recommended

Isolated secundum atrial septal defect Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 mo)

Previous coronary artery bypass graft surgery Mitral valve prolapse without valvar regurgitation

Physiologic, functional, or innocent heart murmurs

Previous rheumatic fever without valve dysfunction Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

 
 

Endocarditis prophylaxis not recommended

 

Restorative dentistry with or without retraction cord

Local anesthetic injections

Intracanal endodontic treatment; post placement and buildup

Placement of rubber dams

Postoperative suture removal

Placement of removable prosthodontic or orthodontic appliances

Taking of oral impressions Fluoride treatments

Taking of oral radiographs

Orthodontic appliance adjustment Shedding of primary teeth