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Full text of "Contemporary Oral and Maxillofacial Surgery,4th Ed Part II Principle of Exodontia"

Prevention and 
Management of 
Surgical 
Complications 



Larry j. Peterson 



Chapter outline 







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C H A PIER 



PREVENTION OF COMPLICATIONS 
SOFTT1SSUE INJURIES 

Tearing Mucosal Flap 

Puncture Wound of Soft Tissue 

Stretch or Abrasion Injury COMPLICATIONS WITH THE 
TOOTH BEING EXTRACTED 

Root Fracture 

Root Displacement 

Tooth Lost into Oropharynx 
INJURIES TO ADJACENT TEETH 

fracture of Adjacent Restoration 

Luxation of Adjacent Teeth 

Extraction of Wrong Teeth 



INJURIES TO OSSEOUS STRUCTURES 
Fracture of Alveolar Process 
Fracture of Maxillary Tuberosity 

INJURIES TO ADJACENT STRUCTURES 
Injury to Regional Nerves 
Injury to Temporomandibular Joint 

OROANTRAL COMMUNICATIONS 

POSTOPERATIVE BLEEDING DELAYED 

HEALING AND INFECTION 
Infection 

Wound Dehiscence 
Dry Socket 

FRACTURES OF THE MANDIBLE 

SUMMARY 



»^_* 




his chapter discusses the variety of 
complications of oral surgical procedures. 
It is divided into two sections, 
intraoperative and postoperative 
complications. These are surgical, not medical, com- 
plications; the latter are discussed in Chapter 3. 

PREVENTION OF COMPLICATIONS 

It is axiomatic that the best and easiest way to manage a 
complication is to prevent it from happening. Prevention 
of surgical complications is best accomplished by a thor- 
ough preoperative assessment and comprehensive treat- 
ment plan. Only when these are routinely performed can 
the surgeon expect to have minimal complications. It is 
important to realize that even with such planning, com- 



plications occasionally occur. In situations in which the 
dentist has planned carefully, the complication is often 
expected and can be managed in a routine manner. For 
example, when extracting a maxillary first premolar, 
which has long thin roots, it is far easier to remove the 
buccal root than the palatal root. Therefore the surgeon 
uses more force toward the buccal root than toward the 
palatal root. If a root does fracture, it is then the buccal 
root rather than the palatal root, and the subsequent 
retrieval is easier. 

Surgeons must perform surgery that is within their 
own ability. Surgeons must therefore carefully evaluate 
their training and ability before deciding to perform a 
specific surgical task. It is inappropriate for a dentist with 
limited experience in the management of impacted third 



221 



222 PART II Principles ofExodontla 



molars to undertake the surgical extraction of a deeply 
embedded tooth. 

The incidence of operative and postoperative compli- 
cations is unacceptably high in this situation. Surgeons 
must be cautious of unwarranted optimism, which 
clouds their judgment and prevents them from deliver- 
ing the best possible care to the patient. The dentist must 
keep in mind that referral to a specialist is an option that 
should always be exercised if the planned surgery is 
beyond the dentist's own skill level. In some situations 
this is not only a moral obligation but also a medicole- 
gal responsibility. 

In planning a surgical procedure, the first step is 
always a thorough review of the patient's medical histo- 
ry. Several of the complications to be discussed in this 
chapter are caused by inadequate attention to medical 
histories that would have revealed the presence of a com- 
plicating factor. Patients with compromised physical sta- 
tus will have local surgical complications that could have 
been prevented had the surgeon taken a more thorough 
medical history. 

One of the primary ways to prevent complications is 
by taking adequate radiographs and reviewing them care- 
fully (see Chapter 7). The radiograph must include the 
entire area of surgery, including the apices of the roots of 
the teeth to be extracted and the local and regional 
anatomic structures, such as the maxillary sinus and the 
inferior alveolar canal. The surgeon must look for the 
presence of abnormal tooth root morphology. After care- 
ful examination of the radiographs, the surgeon must 
occasionally alter the treatment plan to prevent the com- 
plications that might be anticipated with a routine for- 
ceps (closed) extraction. Instead, the surgeon should con- 
sider surgical approaches to removing teeth in such cases. 

After an adequate medical history has been taken and 
the radiographs have been analyzed, the surgeon must do 
the preoperative planning. This is not simply a prepara- 
tion of a detailed surgical plan but is also a plan for man- 
aging patient anxiety and pain and postoperative recov- 
ery (instructions and modifications of normal activity for 
the patient). Thorough preoperative instructions and 
explanations for the patient are essential in preventing 
the majority of complications that occur in the postoper- 
ative period. If the instructions are not thoroughly 
explained or their importance made clear, the patient is 
less likely to follow them. 

Finally, to keep complications at a minimum, the sur- 
geon must always follow the basic surgical principles. 
There should always be clear visualization and access to 
the operative field, which requires adequate light, ade- 
quate soft tissue reflection (including lips, cheeks, tongue, 
and soft tissue flaps), and adequate suction. The teeth to 
be removed must have an unimpeded pathway for 
removal. Occasionally, bone must be removed and teeth 
must be sectioned to achieve this goal. Controlled force is 
of paramount importance; this means "finesse," not 
"force." The surgeon must follow the principles of asepsis, 
atraumatic handling of tissues, hemostasis, and thorough 
debridement of the wound after the surgical procedure. 
Violation of these principles leads to an increased inci- 
dence and severity of surgical complications. 



. V."( ■ ■ ■ • ."'■' 



BOX 11-1 



Prevention of Soft Tissue Injuries 



■ 



1 . Pay strict attention to soft tissue injuries, 

2. Develop adequate-sized flaps. 

3. Use minimal force for retraction of soft tissue, 



SOFT TISSUE INJURIES 

Injuries to the soft tissue of the oral cavity are almost 
always the result of the surgeon's lack of adequate after 
tion to the delicate nature of the mucosa and the use of 
excessive and uncontrolled force. The surgeon must con- 
tinue to pay careful attention to the soft tissue while work- 
ing primarily on the bone and tooth structure (Box 11-1), 

Tearing Mucosal Flap 

The most common soft tissue injury is the tearing of the 
mucosal flap during surgical extraction of a tooth. This is 
usually the result of an inadequately sized envelope flap, 
which is retracted beyond the tissue's ability to stretch 
(Fig. 11-1). This results in a tearing, usually at one end of 
the incision. Prevention of this complication is twofold: 
(1) create adequately sized flaps to prevent excess tension 
on the flap, and (2) use small amounts of retraction force 
on the flap. If a tear does occur in the flap, the flap should 
be carefully repositioned once the surgery is complete. In 
most patients, careful suturing of the tear results in ade- 
quate but delayed healing. If the tear is especially jagged, 
the surgeon may consider excising the edges of the torn 
flap to create a smooth flap margin for closure. This lat- 
ter step should be performed with caution, because exci- 
sion of excessive amounts of tissue leads to closure of the 
wound under tension and probable wound dehiscence, 
If the area of surgery is near the apex of a tooth, an 
increased incidence of envelope-flap tearing exists as a 
result of excessive refractional forces. In this situation a 
release incision to create a three-cornered flap should be 
used to gain access to the bone. 

Puncture Wound of Soft Tissue 

The second soft tissue injury that occurs with some fre- 
quency is inadvertent puncturing of the soft tissue. 
Instruments, such as a straight elevator or periosteal ele- 
vator, may slip from the surgical field and puncture or 
tear into adjacent soft tissue. 

Once again, this injury is the result of using uncon- 
trolled force instead of finesse and is best prevented by 
the use of controlled force, with special attention given to 
the supporting fingers or support from the opposite hand 
in anticipation of slippage. If the instrument slips from 
the tooth or bone, the fingers thus catch the hand before 
injury occurs (Fig. 11-2). When a puncture wound does 
occur, the treatment is aimed primarily at preventing 
infection and allowing healing to occur, usually by sec- 
ondary intention. If the wound bleeds excessively, it 



Prevention and Management of Surgical Complications 



CHAPTER 1 \ 



223 




FIG. 11-1 Periosteal elevator (Seldin elevator) is used to reflect mucoperiosteal flap. 
Elevator placed perpendicular to bone and held in place by pushing firmly against 
bone, not by pushing it apically against soft tissue (arrow). 



should be controlled by direct pressure on the soft tissue. 
Once hemostasis is achieved, the wound is usually left 
open and not sutured, so that if a small infection were to 
occur, there would be an adequate pathway for drainage. 

Stretch or Abrasion Injury 

Abrasions or burns of the lips and corners of the mouth 
are usually the result of the rotating shank of the bur rub- 
bing on the soft tissue (Fig. 11-3). When the surgeon is 
focused on the cutting end of the bur, the assistant should 
be aware of the location of the shank of the bur in relation 
to the cheeks and lips. If such an abrasion does develop, 
the dentist should advise the patient to keep it covered 
with Vaseline or an antibiotic ointment. It is important 
that the patient keeps the ointment only on the abraded 
area and not spread onto intact skin, because it is quite 
likely to result in a rash. These abrasions usually take 5 to 
10 days to heal. The patient should keep the area moist 
with the ointment during the entire healing period to pre- 
vent eschar formation, scarring, and delayed healing, as 
well as to keep the area reasonably comfortable. 

COMPLICATIONS WITH THE TOOTH 
BEING EXTRACTED 

Root Fracture 

The most common complication associated with the 
tooth being extracted is fracture of its roots. Long, 
curved, divergent roots that lie in dense bone are most 
likely to be fractured. The main method of preventing 




2 Small straight elevator can be used as 
shoehorn to luxate broken root. When straight elevator is 
used in this position, hand must be securely supported on 
adjacent teeth to prevent inadvertent slippage of 
instrument from tooth and subsequent injury to adjacent 
tissue. 



224 PART IT 



l^inciples ofExodontia 




FIG. 11-3 A, Abrasion of lip as result of shank of bur rotating on soft tissue. Wound 
should be kept covered with antibiotic ointment. B, Healing should occur rapidly, as 
observed in this photograph taken 5 days later. 



BOX 11-2 



Prevention of Root and Displacement Fracture 



1 . Always plan for root fracture, 

2. Use surgical (i.e., open) extraction if high probability 
of fracture, 

3. Do not use strong apical force on broken root. 



-«^_ 



fracture of roots is to perform an open extraction tech- 
nique and to remove bone to decrease the amount of 
force necessary to remove the tooth (Box 11-2). Recovery 
of the fractured root with a surgical approach is discussed 
in Chapter 8. 

Root Displacement 

The tooth root that is most commonly displaced into 
unfavorable anatomic spaces is the maxillary molar root, 
which is forced into the maxillary sinus. If a root of a max- 
illary molar is being removed, with a straight elevator 
being used with excess apical pressure as a wedge in the 
periodontal ligament space, the tooth root can be dis- 
placed into the maxillary sinus. If this occurs, the surgeon 
must make several assessments to prescribe the appropriate 
treatment. First, the surgeon must identify the size of the 
root lost into the sinus. It may be a root tip of several mil- 
limeters, an entire tooth root, or the entire tooth. The sur- 
geon must next assess if there has been any infection of the 
tooth or periapical tissues. If the tooth is not infected, 
management is easier than if the tooth has been acutely 
infected. Finally, the surgeon must assess the preoperative 
condition of the maxillary sinus. For the patient who has 



a healthy maxillary sinus, it is easier to manage a displaced 
root than if the sinus has been chronically infected. 

If the displaced tooth fragment is a small (2 or 3 mm) 
root tip and the tooth and sinus have no preexisting 
infection, the surgeon should make a minimal attempt 
at removing the root. First, a radiograph of the fractured 
tooth root should be taken to document its position and 
size. Once that has been accomplished, the surgeon 
should irrigate through the small opening in the socket 
apex and then suction the irrigating solution from the 
sinus via the socket. This occasionally flushes the root 
apex from the sinus through the socket. The surgeon 
should check the suction solution and confirm radio- 
graphically that the root has been removed. If this tech- 
nique is not successful, no additional surgical procedure 
should be performed through the socket, and the root 
tip should be left in the sinus. The small, noninfected 
root tip can be left in place, because it is quite unlikely 
that it will cause any troublesome sequelae. Additional 
surgery in this situation will cause more patient mor- 
bidity than leaving the root tip in situ. If the root tip is 
left in the sinus, measures should be taken similar to 
those taken when leaving any root tip in place. The 
patient must be informed of the decision and given 
proper follow-up instructions. 

The oroantral communication should be managed as 
discussed later, with a figure-of-eight suture over the sock- 
et, sinus precautions, antibiotics, and a nasal spray to pre 
vent infection and keep the ostium open. The most like- 
ly occurrence is that the root apex will fibrose onto the 
sinus membrane with no subsequent problems. If 
tooth root is infected or the patient has chronic sinusitis, 
the patient should be referred to an oral and maxillofacial 
surgeon for removal of the root tip. 

If a large root fragment or the entire tooth is displaced 
into the maxillary sinus, it should be removed (Fig. 11-4). 



Prevention and Management of Surgical Complications 



CHAPTEK 11 



225 | 



The usual method is a Caldwell-Luc approach into the 
maxillary sinus in the canine fossa region and then 
removal of the tooth. The oral and maxillofacial surgeon 
(to whom the patient should be referred) performs this 
procedure (see Chapter 19). 

Impacted maxillary third molars are occasionally dis- 
placed into the maxillary sinus (from which they are 
removed via a Caldwell-Luc approach) or posteriorly into 
the infratemporal space. During elevation of the tooth, 
the elevator may force the tooth posteriorly through the 
periosteum into the infratemporal fossa. The tooth is usu- 
ally lateral to the lateral pterygoid plate and inferior to the 
lateral pterygoid muscle. If good access and light are avail- 
able, the surgeon should make a single cautious effort to 
retrieve the tooth with a hemostat. The tooth is usually 
not visible, and blind probing will result in further dis- 
placement. If the tooth is not retrieved after a single effort, 
the incision should be closed and the operation stopped. 
The patient should be informed that the tooth has been 
displaced and will be removed later. Antibiotics should be 
given to help decrease the possibility of an infection, and 
routine postoperative care should be provided. During the 
initial healing time, fibrosis occurs and stabilizes the tooth 
in a rather firm position. The tooth is removed 4 to 6 
weeks later by an oral and maxillofacial surgeon. 

The displaced tooth lies medial to the ramus of the 
mandible and may interfere with wide opening of the 
mouth. In addition, the occurrence of a late infection is 
possible. Although possible, it is very unlikely that the 
tooth will migrate after initial fibrosis has occurred. If no 
mandibular restriction exists, the patient may elect not to 
have the tooth removed. If this decision is made, the sur- 
geon must document that the patient understands the 
situation and the potential complications. 

Fractured mandibular molar roots that are being re- 
moved with apical pressures may be displaced through 
the lingual cortical plate and into the submandibular fas- 
cial space. The lingual cortical bone over the roots of the 
molars becomes thinner as it progresses posteriorly. 
Mandibular third molars, for example, frequently have 
dehiscence in the overlying lingual bone and may be 
actually sitting in the submandibular space preoperative- 
ly. Even small amounts of apical pressure result in dis- 
placement of the root into that space. Prevention of dis- 
placement into the submandibular space is primarily 
achieved by avoiding all apical pressures when removing 
the mandibular roots. 

Pennant-shaped elevators, such as the Cryer, are used 
to elevate the broken tooth root. If the root disappears 
during the root removal, the dentist should make a single 
effort to remove it. The index finger of the left hand is 
inserted onto the lingual aspect of the floor of the mouth 
in an attempt to place pressure against the lingual aspect 
of the mandible and force the root back into the socket. 
If this works, the surgeon may be able to tease the root 
out of the socket with a root tip pick. If this effort is not 
successful on the initial attempt, the dentist should aban- 
don the procedure and refer the patient to an oral and 
maxillofacial surgeon. The usual, definitive procedure of 
removing such a root tip is to reflect a soft tissue flap on 
the lingual aspect of the mandible and gently dissect the 



■•■.' ■ 





B 



FIG. 1 1 -4 A, Large root fragment displaced into maxillary 
sinus. Fragment should be removed with Caldwell-Luc 
approach. B, Tooth in maxillary sinus is maxillary third 
molar that was displaced into sinus during elevation of 
tooth. This tooth must be removed from sinus, probably 
via a Caldwell-Luc approach. 



overlying mucoperiosteum until the root tip can be 
found. As with teeth that are displaced into the maxillary 
sinus, if the root fragment is small and was not infected 
preoperatively, the oral and maxillofacial surgeon may 
elect to leave the root in its position, because surgical 
retrieval of the root may be an extensive procedure. 



226 PART JI 



Principles ufExodontla 



Tooth Lost into Oropharynx 

Occasionally, the crown of a tooth or an entire tooth 
might be lost down the oropharynx. If this occurs, the 
patient should be turned toward the dentist, into a 
mouth-down position, as much as possible. The suction 
device can then be used to help remove the tooth. The 
patient should be encouraged to cough and spit the tooth 
out onto the floor. 

In spite of these efforts, the tooth may be swallowed or 
aspirated. If the patient has no coughing or respiratory 
distress, it is most likely that the tooth was swallowed and 
has traveled down the esophagus into the stomach. How- 
ever, if the patient has a violent episode of coughing that 
continues, the tooth may have been aspirated beyond the 
larynx into the trachea. 

In either case the patient should be transported to an 
emergency room and chest and abdominal radiographs 
taken to determine the specific location of the tooth. If 
the tooth has been aspirated, consultation should be 
requested regarding the possibility of removing the tooth 
with a bronchoscope. The urgent management of aspira- 
tion is to maintain the patient's airway and breathing. 
Supplemental oxygen may be appropriate if respiratory 
distress appears to be occurring. 

If the tooth has been swallowed, it is highly probable 
that it will pass through the gastrointestinal (GI) tract 
within 2 to 4 days. Because teeth are not usually jagged or 
sharp, unimpeded passage occurs in almost all situations. 
However, it may be prudent to have the patient go to an 
emergency room and have a radiograph of the abdomen 
taken to confirm the tooth's presence in the GI tract 
instead of in the respiratory tract. Follow-up radiographs 
are probably not necessary, because the usual fate of swal- 
lowed teeth is passage. 



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. The surgeon should mentally step back from 
time to time to survey the entire surgical field to prevent 
injury to adjacent teeth. 



Fracture of Adjacent Restoration 

The most common injury to adjacent teeth is the inad- 
vertent fracture of either a restoration or a severely cari- 
ous tooth while the surgeon is attempting to luxate the 
tooth to be removed with an elevator (Fig. 1 1-5). If a large 
restoration exists, the surgeon should warn the patient 
preoperatively about the possibility of fracturing it during 
the extraction. Prevention of such a fracture is primarily 
achieved by avoiding application of instrumentation and 
force on the restoration (Box 11-3). This means that the 
straight elevator should be used with great caution or not 
used at all to luxate the tooth before extraction. If a 



BOX 1 1 -3 



Prevention of Injury to Adjacent Teeth 



1* Recognize potential to fracture large restoration. 

2. Warn patient preoperatively, 

3. Employ judicious use of elevators. 

4. Ask assistant to warn surgeon of pressure on adjacent 
teeth. 




FIG. 1 1-5 Mandibular first molar. If it is to be removed, surgeon must take care 
not to fracture amalgam in second premolar with elevators or forceps. 



Prevent km and Management of Surgical Complications 



CHAPTER 11 



227 



restoration is dislodged or fractured, the surgeon should 
make sure that the displaced restoration is removed from 
the mouth and does not fall into the empty tooth socket. 
Once the surgical procedure has been completed, the 
injured tooth should be treated by placement of a tem- 
porary restoration. The patient should be informed that 
the fracture has occurred and that a replacement restora- 
tion must be placed (see Chapter 12). 

Teeth in the opposite arch may also be injured as a 
result of uncontrolled tractional forces. This usually 
occurs when buccolingual forces inadequately mobilize a 
tooth and excessive tractional forces are used. The tooth 
suddenly releases from the socket, and the forceps strikes 
against the teeth of the opposite arch and chips or frac- 
tures a cusp. This is more likely to occur with extraction 
of lower teeth, because these teeth may require more ver- 
tical tractional forces for their delivery, especially when 
using the no. 23 (cowhorn) forceps. Prevention of this 
type of injury can be accomplished by several methods. 
First and primary, the surgeon should avoid the use of 
excessive tractional forces. The tooth should be ade- 
quately luxated with apical, buccolingual, and rotational 
forces to minimize the need for tractional forces. 

Even when this is done, however, occasionally a tooth 
releases unexpectedly. The surgeon or assistant should 
protect the teeth of the opposite arch by simply holding 
a finger or suction tip against them to absorb the blow 
should the forceps be released in that direction. If such an 
injury occurs, the tooth should be smoothed or restored 
as necessary to keep the patient comfortable until a per- 
manent restoration can be constructed. 



Luxation of Adjacent Teeth 

Inappropriate use of the extraction instruments may lux- 
ate the adjacent tooth. This is prevented by judicious use 
of force with elevators and forceps. If the tooth to be 



extracted is crowded and has overlapping adjacent teeth, 
such as is commonly seen in the mandibular incisor 
region, thin, narrow forceps such as the no. 286 forceps, 
may be useful for the extraction (Fig. 11-6). Forceps with 
broader beaks should be avoided, because it will cause 
injury and luxation of the adjacent teeth. 

If an adjacent tooth is luxated or partially avulsed, the 
treatment goal is to reposition the tooth into its appro- 
priate position and stabilize it so that adequate healing 
occurs. This usually requires that the tooth simply be 
repositioned in the tooth socket and left alone. 

The occlusion should be checked to ensure that the 
tooth has not been displaced into a hypererupted and 
traumatic occlusion. Occasionally, the luxated tooth is 
very mobile. If this is the case, the tooth should be stabi- 
lized with the least possible rigid fixation to maintain the 
tooth in its position. A simple silk suture that crosses the 
occlusal table and is sutured to the adjacent gingiva is 
usually sufficient. Rigid fixation with circumdental wires 
and arch bars results in increased chances for external 
root resorption and ankylosis of the tooth; therefore it 
should usually be avoided (see Chapter 23). 

Extraction of Wrong Teeth 

A complication that every dentist believes can never 
happen — but happens surprisingly often — is extraction of 
the wrong tooth. This should never occur if appropriate 
attention is given to the planning and execution of the 
surgical procedure. 

This problem may be the result of inadequate atten- 
tion to the preoperative assessment. If the tooth to be 
extracted is grossly carious, it is less likely that the wrong 
tooth will be removed. The wrong tooth is most com- 
monly extracted when the dentist is asked to remove 
teeth for orthodontic purposes, especially from patients 
who are in mixed dentition stages and whose orthodon- 





B 



FIG. 1 1-6 A, No. 151 forceps, too wide to grasp premolar to be extracted without 
luxating adjacent teeth. B, Maxillary root forceps, which can be adapted easily to tooth 
for extraction. 



228 PART 11 



Principles of Exoifo nth 



BOX 11-4 



Prevention of Extraction of Wrong Teeth 






1 . Focus attention on procedure. 

2. Enlist patient and assistant to ensure correct tooth is 
being removed. 

3. Check, then recheck, to confirm correct tooth. 



tists have asked for unusual extractions. Careful preoper- 
ative planning and clinical assessment of which tooth is 
to be removed before the forceps is applied is the main 
method of preventing this complication (Box 11-4). 

If the wrong tooth is extracted and the dentist realizes 
this error immediately, the tooth should be replaced 
immediately into the tooth socket. If the extraction is for 
orthodontic purposes, the dentist should contact the 
orthodontist immediately and discuss whether or not the 
tooth that was removed can substitute for the tooth that 
should have been removed. If the orthodontist believes 
the original tooth must be removed, the correct extraction 
should be deferred for 4 or 5 weeks, until the fate of the 
replanted tooth can be assessed. If the wrongfully extract- 
ed tooth has regained its attachment to the alveolar 
process, then the originally planned extraction can pro- 
ceed. The surgeon should not extract the contralateral 
tooth until a definite alternative treatment plan is made. 

If the surgeon does not recognize that the wrong tooth 
was extracted until the patient returns for a postoperative 
visit, little can be done to correct the problem. Replanta- 
tion of the extracted tooth after it has dried cannot be 
successfully accomplished. 

When the wrong tooth is extracted, it is important to 
inform the patient, the patient's parents (if the patient is 
a minor), and any other dentist involved with the 
patient's care, such as the orthodontist. In some situa- 
tions the orthodontist may be able to adjust the treat- 
ment plan so that extraction of the wrong tooth necessi- 
tates only a minor adjustment. 

INJURIES TO OSSEOUS STRUCTURES 

Fracture of Alveolar Process 

The extraction of a tooth requires that the surrounding 
alveolar bone be expanded to allow an unimpeded path- 
way for tooth removal. However, in some situations the 
bone fractures and is removed with the tooth instead of 
expanding. The most likely cause of fracture of the alve- 
olar process is the use of excessive force with forceps, 
which fractures large portions of cortical plate. If the sur- 
geon realizes that excessive force is necessary to remove a 
tooth, a soft tissue flap should be elevated and controlled 
amounts of bone removed so that the tooth can be easily 
delivered. If this principle is not adhered to and the den- 
tist continues to use excessive or uncontrolled force, frac- 
ture of the bone will probably occur. 

The most likely places for bony fracture are the buccal 
cortical plate over the maxillary canine, the buccal cortical 




FIG. II- 7 Forceps extraction of these teeth resulted in 
removal of bone and tooth instead of just tooth. 



. 



BOX 11-5 




Prevention of Fracture of Alveolar Process 



1 . Conduct thorough preoperative clinical and radio- 
graphic examination. 

2. Do not use excessive force, 

3. Use surgical (i.e., open) extraction technique to 
reduce force required. 



plate over the maxillary molars (especially the first molar), 
the portions of the floor of the maxillary sinus associated 
with maxillary molars, the maxillary tuberosity, and the 
labial bone on mandibular incisors (Fig. 11-7). All of these 
bony injuries are caused by excessive force from the forceps. 

The primary method of preventing these fractures is to 
perform a careful preoperative examination of the alveo- 
lar process, both clinically and radiographically (Box 
11-5). Surgeons should inspect the root form of the tooth 
to be removed and assess the proximity of the roots to the 
maxillary sinus (Fig. 11-8). They should also check the 
thickness of the buccal cortical plate overlying the tooth 
to be extracted (Fig, 11-9). If the roots diverge widely, if 
they lie close to the sinus, or if the patient has a heavy 
buccal cortical bone, surgeons must take special measures 
to prevent fracturing excessive portions of bone. Age is a 
factor to be considered, because the bones of older 
patients are likely to be less elastic and therefore mon 
likely to fracture rather than expand. 

The surgeon who preoperatively determines that a 
high probability exists for bone fracture should consider 
performing the extraction by the surgical technique, 
Using this method the surgeon can remove a smaller, 



Prevention and Management of Surgical Complications 



CHAPTER 11 



229 




B 



FIG. 11-8 A, Floor of sinus associated with roots of teeth. If extraction is required, tooth 
should be removed surgically. B, Maxillary molar teeth immediately adjacent to sinus present 
increased danger of sinus exposure. 



more controlled amount of bone, which results in more 
rapid healing and a more ideal ridge form for prosthetic 
reconstruction. 

When the maxillary molar lies close to the maxillary 
anus, surgical exposure of the tooth, with sectioning of 
the tooth roots into two or three portions, will prevent 
the removal of a portion of the maxillary sinus floor. This 
prevents the formation of a chronic oroantral fistula, 
which requires secondary procedures to close. 

In summary, prevention of fractures of large portions of 
the cortical plate depends on preoperative radiographic 
and clinical assessment, avoidance of the use of excessive 
amounts of uncontrolled force, and the early decision to 
perform an open extraction with removal of controlled 
amounts of bone and sectioning of multirooted teeth. 



During a forceps extraction, if the appropriate amount of 
tooth mobilization does not occur early, then the wise and 
prudent dentist will alter the treatment plan to the surgi- 
cal technique instead of pursuing the closed method. 

Management of fractures of the alveolar bone takes sev- 
eral different routes, depending on the type and severity 
of the fracture: If the bone has been completely removed 
from the tooth socket along with the tooth, it should not 
be replaced. The surgeon should simply make sure that 
the soft tissue has been replaced and repositioned over the 
remaining bone to prevent delayed healing. The surgeon 
must also smooth any sharp edges that may have been 
caused by the fracture. If such sharp edges of bone exist, 
the surgeon should reflect a smalt amount of soft tissue 
and use a bone file to round off the sharp edges. 



230 PARTH 



Principles ofExodontia 




FIG. 11-9 Patient with heavy buccal cortical plate who requires open extraction. 



The surgeon who has been supporting the alveolar 
process with the fingers during the extraction will feel the 
fracture of the buccal cortical plate when it occurs. At this 
time the bone remains attached to the periosteum and 
will heal if it can be separated from the tooth and left 
attached to the overlying soft tissue. The surgeon must 
carefully dissect the bone with its attached associated soft 
tissue away from the tooth. For this procedure the tooth 
must be stabilized with the forceps, and a small sharp 
instrument, such as a Woodson periosteal elevator, 
should be used to elevate the buccal bone from the tooth 
root. It is important to realize that if the soft tissue flap is 
reflected from the bone, the blood supply to the overly- 
ing bone will be severed and the bone will then undergo 
necrosis. Once the bone and soft tissue have been elevat- 
ed from the tooth, the tooth is removed and the bone 
and soft tissue flap are reapproximated and secured with 
sutures. When treated in this fashion, it is highly proba- 
ble that the bone will heal in a more favorable ridge form 
for prosthetic reconstruction than if the bone had been 
removed along with the tooth. Therefore it is worth the 
special effort to dissect the bone from the tooth. 

Fracture of Maxillary Tuberosity 

Fracture of a large section of bone in the maxillary 
tuberosity area is a situation of special concern. The max- 
illary tuberosity is especially important for the construc- 
tion of a stable retentive maxillary denture. If a large 
portion of this tuberosity is removed along with the max- 
illary tooth, denture stability may be compromised. The 
fracture of the maxillary tuberosity most commonly 
results from extraction of an erupted maxillary third 
molar or from a second molar if it happens to be the last 
tooth in the arch (Fig. 11-10). 

If this type of fracture occurs during an extraction, 
treatment is similar to that just discussed for other bony 



fractures. The surgeon using finger support for the alveolar 
process during the fracture (if the bone remains attached to 
the periosteum) should take extreme measures to ensure 
the survival of that bony segment. If at all possible the 
bony segment should be dissected away from the tooth 
and the tooth removed in the usual fashion. The tuberosi- 
ty is then stabilized with sutures as previously indicated. 

However, if the tuberosity is excessively mobile and 
cannot be dissected from the tooth, the surgeon has sev- 
eral options. The first option is to splint the tooth being 
extracted to adjacent teeth and defer the extraction for 6 
to 8 weeks, during which time the bone will heal. The 
tooth is then extracted with an open surgical technique. 
The second option is to section the crown of the tooth 
from the roots and allow the tuberosity and tooth root 
section to heal. After 6 to 8 weeks the surgeon can reen- 
ter the area and remove the tooth roots in the usual fash- 
ion. If the maxillary molar tooth is infected, these two 
techniques should be used with caution. 

If the maxillary tuberosity is completely separated from 
the soft tissue, the usual steps are to smooth the sharp 
edges of the remaining bone and to replace and suture the 
remaining soft tissue. The surgeon must carefully check 
for an oroantral communication and treat as necessary. 

Fractures of the maxillary tuberosity should be viewed 
as a serious complication. The major therapeutic goal of 
management is to maintain the fractured bone in place 
and to provide the best possible environment for healing, 
This may be a situation that can best be handled by refer- 
ral to an oral and maxillofacial surgeon. 

INJURIES TO ADJACENT STRUCTURES 

During the process of tooth extraction, it is possible to 
injure adjacent tissues. The prudent surgeon preopera- 
tively evaluates all adjacent anatomic areas and designs a 
surgical procedure to prevent injury to these tissues. 



Prevention and Management of Surgical Complications 



CHAPTER 11 



231 







BOX 11-6 



Prevention of Nerve Injury 



•■.•■.:■ r "/. , ;.-\y.:' i .'.. 



FIG. 11-10 Tuberosity removed with maxillary second 
molar, which eliminates important prosthetic retention area 
and exposes maxillary sinus. A, Buccal view of bone 
removed with tooth. B, Superior view, looking onto sinus 
floor, which was removed with tooth. 



Injury to Regional Nerves 

The branches of the fifth cranial nerve, which provide 
innervation to the mucosa and skin, are the structures 
most likely to be injured during extraction. The most fre- 
quently involved specific branches are the mental nerve, 
the lingual nerve, the buccal nerve, and the nasopalatine 
nerve. The nasopalatine and buccal nerves are frequently 
sectioned during the creation of flaps for removal of 
impacted teeth. The area of sensory innervation of these 
two nerves is relatively small, and reinnervation of the 
affected area usually occurs rapidly. Therefore the 
nasopalatine and long buccal nerves can be surgically sec- 
tioned without sequelae or complications. 

Surgical removal of mandibular premolar roots or 
impacted mandibular premolars and periapical surgery in 



1 ; Be aware of nerve anatomy in surgical area. 
2. Avoid making incisions or affecting periosteum in 
nerve area. 



the area of the mental nerve and mental foramen must be 
performed with great care. If the mental nerve is injured, 
the patient will have an anesthesia or paresthesia of the 
lip and chin. If the injury is the result of flap reflection or 
simple manipulation, the altered sensation usually disap- 
pears in a few weeks to a few months. If the mental nerve 
is sectioned at its exit from the mental foramen or torn 
along its course, it is likely that mental nerve function will 
not return, and the patient will have a permanent state of 
anesthesia. If surgery is to be performed in the area of the 
mental nerve or the mental foramen, it is imperative that 
surgeons have a keen awareness of the potential morbidity 
from injury to this nerve (Box 11-6). If surgeons have any 
question concerning their ability to perform the indicated 
surgical procedure, they should refer the patient to an 
oral and maxillofacial surgeon. If a three-corner flap is to 
be used in the area of the mental nerve, the vertical 
releasing incision must be placed far enough anterior to 
avoid severing any portion of the mental nerve. Rarely is 
it advisable to make the vertical releasing incision at the 
interdental papilla between the canine and first premolar. 

The lingual nerve is anatomically located directly against 
the lingual aspect of the mandible in the retromolar pad 
region. The lingual nerve rarely regenerates if it is severely 
traumatized. Incisions made in the retromolar pad region of 
the mandible should be placed to avoid severing this nerve. 
Therefore incisions made for surgical exposure of impacted 
third molars or of bony areas in the posterior molar region 
should be made well to the buccal aspect of the mandible. 
Prevention of injury to the lingual nerve is of paramount 
importance for controlling this difficult complication. 

Finally, the inferior alveolar nerve may be traumatized 
along the course of its intrabony canal. The most common 
place of injury is the area of the mandibular third molar. 
Removal of impacted third molars may crush or sharply 
injure the nerve in its canal. This complication is common 
enough during the extraction of third molars that it is 
important to inform patients on a routine basis that it is a 
possibility. The surgeon must then take every precaution 
possible to avoid injuring the nerve during the extraction. 

Injury to Temporomandibular Joint 

Another major structure that can be traumatized during 
an extraction procedure in the mandible is the temporo- 
mandibular joint (TMJ). Removal of mandibular molar 
teeth frequently requires the application of a substantial 
amount of force. If the jaw is inadequately supported dur- 
ing the extraction, the patient may experience pain in this 
region. Controlled force and adequate support of the jaw 
prevents this. The use of a bite block on the contralateral 



232 PART II 



Principles ofExodontia 



• 



BOX 11-7 



Prevention of Injury to Temporomandibular Joint 



1. Support mandible during extraction. 

2. Do not open mouth too widely. 



BOX 11-8 



Prevention of Oroantral Communications 



1 . Conduct thorough preoperative radiographic 
examination. 

2. Use surgical extraction early and section roots. 

3. Avoid excess apical pressure. 



side may provide adequate balance of forces so that injury 
and pain do not occur (Box 11-7). The surgeon must also 
support the jaw as described earlier. If the patient com- 
plains of pain in the TMJ immediately after the extraction 
procedure, the surgeon should recommend the use of 
moist heat, rest for the jaw, a soft diet, and 1000 mg of 
aspirin every 4 hours for several days. Patients who cannot 
tolerate aspirin should be given an aspirin substitute, such 
as other NSAIDs or acetaminophen. 

OROANTRAL COMMUNICATIONS 

Removal of maxillary molars occasionally results in com- 
munication between the oral cavity and the maxillary 
sinus. If the maxillary sinus is large, if no bone exists 
between the roots of the teeth and the maxillary sinus, 
and if the roots of the tooth are widely divergent, then it 
is increasingly probable that a portion of the bony floor 
of the sinus will be removed with the tooth. If this com- 
plication occurs, appropriate measures are necessary to 
prevent a variety of sequelae. The two sequelae of most 
concern are postoperative maxillary sinusitis and forma- 
tion of a chronic oroantral fistula. The probability that 
either of these two sequelae will occur is related to the 
size of the oroantral communication and the manage- 
ment of the exposure. 

As with all complications, prevention is the easiest and 
most efficient method of managing the situation. Preop- 
erative radiographs must be carefully evaluated for the 
tooth-sinus relationship whenever maxillary molars are 
to be extracted. If the sinus floor seems to be very close to 
the tooth roots and the tooth roots are widely divergent, 
the surgeon should avoid a closed forceps extraction and 
perform a surgical removal with sectioning of tooth roots 
(see Fig. 11-8). Large amounts of force should be avoided 
in the removal of such maxillary molars (Box 11-8). 

Diagnosis of the oroantral communication can be 
made in several ways: The first is to examine the tooth 
once it is removed. If a section of bone is adhered to the 
root ends of the tooth, the surgeon can be relatively cer- 
tain that a communication between the sinus and mouth 
exists. If a small amount of bone or no bone adheres to 
the molars, a communication may exist anyway. To con- 
firm the presence of a communication, the best tech- 
nique is to use the nose-blowing test. Pinching the nos- 
trils together occludes the patient's nose, and the patient 
is asked to blow gently through the nose while the sur- 
geon observes the area of the tooth extraction. If a com- 
munication exists, there will be passage of air through the 
tooth socket and bubbling of blood in the socket area. 



After the diagnosis of oroantral communication has 
been established, the surgeon must determine the approx- 
imate size of the communication, because the treatment 
will depend on the size of the opening. If the communi- 
cation is small (2 mm in diameter or less), no additional 
surgical treatment is necessary. The surgeon should take 
measures to ensure the formation of a high-quality blood 
clot in the socket and then advise the patient to take sinus 
precautions to prevent dislodgment of the blood clot. 

Sinus precautions are aimed at preventing increases or 
decreases in the maxillary sinus air pressure that would 
dislodge the clot. Patients should be advised to avoid 
blowing the nose, violent sneezing, sucking on straws, 
and smoking. Patients who smoke and who cannot stop 
(even temporarily) should be advised to smoke in small 
puffs, not in deep drags, to avoid pressure changes. 

The surgeon must not probe through the socket into 
the sinus with a periapical curette or a root tip pick. It is 
possible that the bone of the sinus has been removed with- 
out perforation of the sinus lining. To probe the socket 
with an instrument might unnecessarily lacerate the mem- 
brane. Probing of the communication may also introduce 
foreign material, including bacteria, into the sinus and 
thereby further complicate the situation. Probing of the 
communication is therefore absolutely contraindicated. 

If the opening between the mouth and sinus is of 
moderate size (2 to 6 mm), additional measures should be 
taken. To help ensure the maintenance of the blood clot 
in the area, a figure-of-eight suture should be placed over 
the tooth socket (Fig. 11-11). The patient should also be 
told to follow sinus precautions. Finally, the patient 
should be prescribed several medications to help lessen 
the possibility that maxillary sinusitis will occur. Antibi- 
otics, usually penicillin or clindamycin, should be pre- 
scribed for 5 days. In addition, a decongestant nasal spray 
should be prescribed to shrink the nasal mucosa to keep 
the ostium of the sinus patent. As long as the ostium is 
patent and normal sinus drainage can occur, sinusitis and 
sinus infection are less likely. An oral decongestant is also 
sometimes recommended. 

If the sinus opening is large (7 mm or larger), the den- 
tist should consider closing the sinus communication with 
a flap procedure. This usually requires that the patient be 
referred to an oral and maxillofacial surgeon, because flap 
development and closure of a sinus opening are somewhat 
complex procedures that require skill and experience. 

The most commonly used flap is a buccal flap. This 
technique mobilizes buccal soft tissue to cover the open- 
ing and provide for a primary closure. This technique 
should be performed as soon as possible, preferably on 



Prevention and Management of Surgical Complications 



CHAPTER 11 



233 




BOX 11-9 



Prevention of Postoperative Bleeding 



FIG. 11-11 A figure-of-eight stitch is usually 
performed to help maintain piece of oxidized cellulose in 
tooth socket. 



the same day in which the opening occurred. The same 
sinus precautions and medications are usually required 
(see Chapter 19). 

The recommendations just described hold true for 
patients who have no preexisting sinus disease. If a com- 
munication does occur, it is important that the dentist 
inquire specifically about a history of sinusitis and sinus 
infections. If the patient has a history of chronic sinus 
disease, even small oroantral communications will heal 
poorly and may result in permanent oroantral communi- 
cation. Therefore creation of an oroantral communica- 
tion in patients with chronic sinusitis is cause for referral 
to an oral and maxillofacial surgeon for definitive care 
(see Chapter 19). 

The majority of oroantral communications treated in 
the methods just recommended will heal uneventfully. 
Patients should be followed up carefully for several weeks 
to ensure that this has occurred. Even patients who return 
within a few days with a small communication usually 
heal spontaneously if no maxillary sinusitis exists. These 
patients should be followed up closely and referred to an 
oral and maxillofacial surgeon if the communication per- 
sists for longer than 2 weeks. Closure of oroantral fisrulae 
is important because air, water, food, and bacteria go from 
the oral cavity into the sinus, often causing a chronic 
sinusitis condition. Additionally, if the patient is wearing 
a full maxillary denture, suction is not as strong; therefore 
retention of the denture is compromised. 

POSTOPERATIVE BLEEDING 



Extraction of teeth is a surgical procedure that presents a 
severe challenge to the body's hemostatic mechanism. 
Several reasons exist for this challenge: First, the tissues of 
the mouth and jaws are highly vascular. Second, the 
extraction of a tooth leaves an open wound, with both 
soft tissue and bone open, which allows additional ooz- 
ing and bleeding. Third, it is almost impossible to apply 
dressing material with enough pressure and sealing to 
prevent additional bleeding during surgery. Fourth, 
patients tend to play with the area of surgery with their 
tongues and occasionally dislodge blood clots, which ini- 
tiates secondary bleeding. The tongue may also cause sec- 
ondary bleeding by creating small negative pressures that 
suction the blood clot from the socket. Finally, salivary 
enzymes may lyse the blood clot before it has organized 
and before the ingrowth of granulation tissue. 



1 . Obtain history of bleeding. 

2. Use atraumatic surgical technique. 

3. Obtain good hemostasts at surgery. 

4. Provide excellent patient instructions. 



As with all complications, prevention of bleeding is 
the best way to manage this problem (Box 11-9). One of 
the prime factors in preventing bleeding is the taking of 
a thorough history from the patient regarding this specif- 
ic potential problem. Several questions should be asked of 
the patient concerning any history of bleeding. If affir- 
mative answers to any of these questions are given, the 
surgeon should take special efforts to control bleeding. 

The first question that patients should be asked is if they 
have ever had a problem with bleeding in the past. The sur- 
geon should inquire about bleeding after previous tooth 
extractions or previous surgery (such as a tonsillectomy) 
and persistent bleeding after accidental lacerations. The sur- 
geon must listen carefully to the patient's answers to these 
questions, because the patient's idea of "persistent" may 
actually be normal. For example, it is quite normal for a 
socket to ooze small amounts of blood for the first 12 to 24 
hours after extraction. However, if a patient relates a histo- 
ry of bleeding that persisted for more than 1 day or that 
required special attention from the dentist, then the sur- 
geon's degree of suspicion should be substantially elevated. 

The surgeon should inquire about any family history 
of bleeding. If anyone in the patient's family has or had 
a history of prolonged bleeding, further inquiry about its 
cause should be pursued. Most congenital bleeding disor- 
ders are familial, inherited characteristics. These congen- 
ital disorders vary from very mild to very profound, the 
latter requiring substantial efforts to control. 

The patient should next be asked about any medica- 
tions currently being taken that might interfere with 
coagulation. Drugs such as anticoagulants may cause 
prolonged bleeding after extraction. Patients receiving 
anticancer chemotherapy or who are alcoholics may also 
tend to bleed. 

The patient who has a known or suspected coagulop- 
athy should be evaluated by laboratory testing before 
surgery is performed to determine the severity of the dis- 
order. It is usually advisable to enlist the aid of a hema- 
tologist if the patient has a familial coagulation disorder. 

The means to measure the status of intentional anti- 
coagulation is to use the International Normalized Ratio 
(INK). This value takes into account both the patient's 
prothrombin time (PT) and the control. Normal antico- 
agulated status for most medical indications will have an 
INR of 2.0 to 3.0. It is reasonable to perform extractions 
on patients who have an INR of 2.5 or less without reduc- 
ing the anticoagulant dose. With special precautions, it is 
reasonably safe to do minor amounts of surgery in 
patients with an INR of up to 3.0, if special local hemo- 
static measures are taken. 



| 234 



PARI II 



Principles of Exodon tia 



Primary control of bleeding during routine surgery 
depends on gaining control of all factors that may pro- 
long bleeding. Surgery should be as atraumatic as possi- 
ble, with clean incisions and gentle management of the 
soft tissue. Care should be taken not to crush the soft tis- 
sue, because crushed tissue tends to ooze for long periods. 
Sharp bony spicules should be smoothed or removed. All 
granulation tissue should be curetted from the periapical 
region of the socket and from around the necks of adja- 
cent teeth and soft tissue flaps. This should be deferred 
when anatomic restrictions, such as the sinus or inferior 
alveolar canal, are present (Fig. 11-12). The wound should 
be carefully inspected for the presence of any specific 
bleeding arteries. If such arteries exist in the soft tissue, 
they should be controlled with direct pressure or, if pres- 
sure fails, by clamping the artery with a hemostat and li- 
gating it with a resorbable suture. For most oral surgical 
procedures, direct pressure over the soft tissue bleeding 
area for 5 minutes results in complete control. 

The surgeon should also check for bleeding from the 
bone. Occasionally, a small, isolated vessel bleeds from a 
bony foramen. If this occurs, the foramen can be crushed 
with the closed ends of the hemostat, thereby occluding 
the bleeding vessel. Once these measures have been 
accomplished, the bleeding socket is covered with a 
damp gauze sponge that has been folded to fit directly 
into the area from which the tooth was extracted. The 
patient bites down firmly on this gauze for at least 30 
minutes. The surgeon should not dismiss the patient 
from the office until hemostasis has been achieved. This 
requires that the surgeon check the patient's extraction 
socket about 1 5 minutes after the completion of surgery. 
The patient should open the mouth widely, the gauze 
should be removed, and the area should be inspected 
carefully for any persistent oozing. Initial control should 
have been achieved. New damp gauze is then folded and 
placed into position, and the patient is told to leave it in 
place for an additional 30 minutes. 



If bleeding persists but careful inspection of the socket 
reveals that it is not of an arterial origin, the surgeon 
should take additional measures to achieve hemostasis. 
Several different materials can be placed in the socket to 
help gain hemostasis (Fig. 11-13). The most commonly 
used and the least expensive is the absorbable gelatin 
sponge (e.g., Gelfoam). This material is placed in the 
extraction socket and held in place with a figure eight 
suture placed over the socket. The absorbable gelatin 
sponge forms a scaffold for the formation of a blood clot, 
and the suture helps maintain the sponge in position dur- 
ing the coagulation process. A gauze pack is then placed 
over the top of the socket and is held with pressure. 

A second material that can be used to control bleeding 
is oxidized regenerated cellulose (e.g., Surgicel). This 
material promotes coagulation better than the absorbable 
gelatin sponge, because it can be packed into the socket 
under pressure. The gelatin sponge becomes very friable 
when wet and cannot be packed into a bleeding socket. 
When the cellulose is packed into the socket, it almost 
always causes delayed healing of the socket. Therefore 
packing the socket with cellulose is reserved for more per- 
sistent bleeding. 

If the surgeon has special concerns about the patient's 
ability to clot, a liquid preparation of topical thrombin 
(prepared from bovine thrombin) can be saturated onto a 
gelatin sponge and inserted into the tooth socket. The 
thrombin bypasses all steps in the coagulation cascade 
and helps to convert fibrinogen to fibrin enzymatically, 
which forms a clot. The sponge with the topical thrombin 
is secured in place with a figure-eight suture. A gauze pack 
is placed over the extraction site in the usual fashion. 

A final material that can be used to help control a 
bleeding socket is collagen. Collagen promotes platelet 
aggregation and thereby helps accelerate blood coagula- 
tion. Collagen is currently available in several different 
forms. Microfibular collagen {e.g., Avitene) is available as 
a fibular material that is loose and fluffy but can be 













FIG. 11-12 Granuloma of second premolar. Surgeon should not curette 
periapically around this second premolar to remove granuloma because risk for 
sinus perforation is high. 



Prevention and Management oj 'Surgical Complications ■ CHAPTER 11 235 




packed into a tooth socket and held in by suturing and 
gauze packs, as with the other materials. A more highly 
cross-linked collagen is supplied as a plug (e.g., Collaplug) 
or as a tape (e.g., Collatape). These materials are more 
readily packed into a socket (Fig. 11-14) and are easier to 
use. They are also more expensive. 

Even after primary hemostasis has been achieved, 
patients occasionally call the dentist with bleeding from the 
extraction site, referred to as secondary bleeding. The 
patient should be told to rinse the mouth gently with very 
cold water, then place appropriate-sized gauze over the area 
and bite firmly. The patient should sit quietly for 30 min- 
utes, biting firmly on the gauze. If the bleeding persists, the 
patient should repeat the cold rinse and bite down on a 
damp tea bag. The tannin in the tea will frequently help 
stop the bleeding. If neither of these techniques is success- 
ful, the patient should return to the dentist. 

The surgeon must have an orderly, planned regimen to 
control this secondary bleeding. The patient should be 
positioned in the dental chair, and all blood, saliva, and 
fluids should be suctioned from the mouth. Such patients 
will frequently have large "liver clots" in their mouth, 
which must be removed. The surgeon should visualize 
the bleeding site carefully with good light to determine 
the precise source of bleeding. If it is clearly seen to be a 



generalized oozing, the bleeding site is covered with a 
folded, damp gauze sponge held in place with firm pres- 
sure by the surgeon's finger for at least 5 minutes. 




FIG. 11-13 Material that can be used in a bleeding 
socket. Clockwise from the canine tooth: collagen plug, 
microfibular colla-gen, regenerated oxidized cellulose, 
collagen tape, and absorbable gelatin sponge. 




B 



D 



FIG. 1 1-14 A, Collagen shaped into the form of a plug is similar in size to the root of a 
maxillary canine. B and C, The collagen plug is placed into the socket with cotton pliers 
(arrow). D, A figure-eight suture is placed over the socket to maintain the collagen in the 
socket. 



236 l'AKT II 



Principles ofExoiiori tin 



This measure is sufficient to control most bleeding. 
The reason for the bleeding is usually some secondary 
trauma that is potentiated by the patient's continuing to 
suck on the area or to spit blood from the mouth instead 
of continuing to appiy pressure with a gauze sponge. 

If 5 minutes of this treatment does not control the 
bleeding, the surgeon must administer a local anesthetic 
so that the socket can be treated more aggressively. Block 
techniques are to be encouraged instead of local infiltra- 
tion techniques. Infiltration with solutions containing 
epinephrine cause vasoconstriction and may control the 
bleeding temporarily. However, when the effects of the 
epinephrine dissipate, rebound hemorrhage with recur- 
rent bothersome bleeding may occur. 

Once local anesthesia has been achieved, the surgeon 
should gently curette out the tooth extraction socket and 
suction all areas of old blood clot. The specific area of 
bleeding should be identified as clearly as possible. As 
with primary bleeding, the soft tissue should be checked 
for diffuse oozing versus specific artery bleeding. The 
bone tissue should be checked for small nutrient artery 
bleeding or general oozing. The same measures described 
for control of primary bleeding should be used. The sur- 
geon must then decide if a hemostatic agent should be 
inserted into the bony socket. The use of an absorbable 
gelatin sponge with topical thrombin held in position 
with a figure-of-eight stitch and reinforced with applica- 
tion of firm pressure from a small, damp gauze pack is 
standard for local control of secondary bleeding. This 
technique works well in almost every bleeding socket. In 
many situations an absorbable gelatin sponge and gauze 
pressure are adequate. The patient should be given spe- 
cific instructions on how to apply the gauze packs direct- 
ly to the bleeding site should additional bleeding occur. 
Before the patient with secondary bleeding is discharged 
from the office, the surgeon should monitor the patient 
for at least 30 minutes to ensure that adequate hemosta- 
tic control has been achieved. 

If hemostasis is not achieved by any of the local meas- 
ures just discussed, the surgeon should consider perform- 
ing additional laboratory screening tests to determine if 
the patient has a profound hemostatic defect. The dentist 
usually requests a consultation from a hematologist, who 
orders the typical screening tests. Abnormal test results 
will prompt the hematologist to investigate the patient's 
hemostatic system further. 

A final hemostatic complication relates to intraopera- 
tive and postoperative bleeding into the adjacent soft 
tissues. Blood that escapes into tissue spaces, especially 
subcutaneous tissue spaces, appears as bruising of the 
overlying soft tissue 2 to 5 days after the surgery. This 
bruising is termed ecchymosis {see Chapter 10). 

DELAYED HEALING AND INFECTION 

Infection 

The most common cause of delayed wound healing is 
infection. Infection is a rare complication after routine 
dental extraction and is primarily seen after oral surgery 
that involves the reflection of soft tissue flaps and bone 



removal. Careful asepsis and thorough wound debride- 
ment after surgery can best achieve prevention of infec- 
tion after surgical flap procedures. This means that the 
area of bone removal under the flap must be copiously 
irrigated with saline and that all foreign debris must be 
removed with a curette. Some patients are predisposed to 
postoperative wound infections and should be given peri- 
operative prophylactic antibiotics (see Chapter 15). 

Wound Dehiscence 

Another problem of delayed healing is wound dehiscence 
(Box 11-10). If a soft tissue flap is replaced and sutured 
without an adequate bony foundation, the unsupported 
soft tissue flap often sags and separates along the line of 
incision. A second cause of dehiscence is suturing the 
wound under tension. If the soft tissue flap is sutured 
under tension, the sutures cause ischemia of the flap mar- 
gin with subsequent tissue necrosis, which allows the 
suture to pull through the flap margin and results in 
wound dehiscence. Therefore sutures should always be 
placed in tissue without tension and tied loosely enough 
to prevent blanching of the tissue. 

A common area of exposed bone after tooth extraction 
is the internal oblique ridge. After extraction of the first 
and second molar, during the initial healing, the lingual 
flap becomes stretched over the internal oblique (mylo- 
hyoid) ridge. Occasionally, the bone will perforate 
through the thin mucosa, causing a sharp projection of 
bone in the area. 

The two major treatment options are (1) to leave the 
projection alone, or (2) to smooth it with bone file. If the 
area is left to heal untreated, the exposed bone will 
slough off in 2 to 4 weeks. If the irritation of the sharp 
bone is low, this is the preferred method. If a bone file is 
used, no flap should be elevated, because this will result 
in an increased amount of exposed bone. The file is used 
only to smooth off the sharp projections of the bone. 
This procedure usually requires local anesthesia. Patients 
who are quite annoyed by the sharp bone will usually 
choose this method. 



Dry Socket 

Dry socket or alveolar osteitis is delayed healing but is not 
associated with an infection. This postoperative complica- 
tion causes moderate-to- severe pain but is without the 
usual signs and symptoms of infection, such as fever, 
swelling, and erythema. The term dry socket describes tin 
appearance of the tooth extraction socket when the pain 



■■■: 






BOX 11-10 



Prevention of Wound Dehiscence 



1 , Use aseptic technique. 

2. Perform atraumatic surgery. 

3 t Close incision over intact bone. 
A, Suture without tension, 



-j 



Prevention and Management of Surgical Complications 



CHAPTER 11 



begins. In the usual clinical course, pain develops on the 
third or fourth day after removal of the tooth. On exami- 
nation the tooth socket appears to be empty, with a par- 
tially or completely lost blood clot, and the bony surfaces 
of the socket are exposed. The exposed bone is extremely 
sensitive and is the source of the pain. The dull, aching 
pain is moderate to severe, usually throbs, and frequently 
radiates to the patient's ear. The area of the socket has a bad 
odor, and the patient frequently complains of a bad taste. 

The cause of alveolar osteitis is not absolutely clear, 
but it appears to be the result of high levels of 
fibrinolyt-ic activity in and around the tooth extraction 
socket. This fibrinolytic activity results in lysis of the 
blood clot and subsequent exposure of the bone. The 
fibrinolytic activity may be the result of subclinical 
infections, inflammation of the marrow space of the 
bone, or other factors. The occurrence of a dry socket 
after a routine tooth extraction is relatively rare (2% of 
extractions), but it is quite frequent after the removal of 
impacted mandibular third molars (20% of extractions). 

Prevention of the dry socket syndrome requires that 
the surgeon minimize trauma and bacterial contamina- 
tion in the area of surgery. The surgeon should perform 
atraumatic surgery with clean incisions and soft tissue 
reflection. After the surgical procedure, the wound 
should be thoroughly debrided and irrigated with large 
quantities of saline. Small amounts of antibiotics (e.g., 
tetracycline) placed in the socket alone or on a gelatin 
sponge may help to decrease the incidence of dry 
socket in mandibular third molars. The incidence of dry 
socket can also be decreased by preoperative and 
postoperative rinses with antimicrobial mouth rinses, 
such as chlorhex-idine. Well-controlled studies indicate 
that the incidence of dry socket after impacted 
mandibular third molar surgery can be reduced by up to 
50%. 

The treatment of alveolar osteitis is dictated by the 
single therapeutic goal of relieving the patient's pain dur- 
ing the period of healing. If the patient receives no treat- 
ment, no sequela other than continued pain exists 
(treatment does not hasten healing). 

Treatment is straightforward and consists of gentle 
irrigation and insertion of a medicated dressing. First, the 
tooth socket is gently irrigated with saline. The socket 
should not be curetted down to bare bone, because this 
increases both the amount of exposed bone and the 
pain. Usually the entire blood clot is not lysed, and the 
part that is intact should be retained. The socket is 
carefully suctioned of all excess saline, and a small 
strip of iodo-form gauze soaked with the medication is 
inserted into the socket. The medication contains the 
following principal ingredients: eugenol, which 
obtunds the pain from the bone tissue; a topical 
anesthetic, such as benzocaine; and a carrying vehicle, 
such as balsam of Peru. The medication can be made by 
the surgeon's pharmacist or can be obtained as a 
commercial preparation from dental supply houses. 

The medicated gauze is gently inserted into the 
socket, and the patient usually experiences profound 
relief from pain within 5 minutes. The dressing is 
changed every day or every other day for the next 3 to 6 
days, depending on the severity of the pain. The 
socket is gently irrigated- 



with saline at each dressing change. Once the 
patient's pain decreases, the dressing should not be 
replaced, because it acts as a foreign body and further 
prolongs wound healing. 

FRACTURES OF THE MANDIBLE 

Fracture of the mandible during extraction is a rare 
complication; it is associated almost exclusively with 
the surgical removal of impacted third molars. A 
mandibular fracture is usually the result of the 
application of a force exceeding that needed to 
remove a tooth and often occurs during the use of 
dental elevators. However, when lower third molars 
are deeply impacted, even small amounts of force may 
cause a fracture. Fractures may also occur during 
removal of impacted teeth from a severely atrophic 
mandible. Should such a fracture occur, it must be 
treated by the usual methods used for jaw fractures. 
The fracture must be adequately reduced and stabilized 
with intermaxillary fixation. Usually this means that 
the patient should be referred to an oral and 
maxillofacial surgeon for definitive care. 



SUMMARY 

Prevention of complications should be a major goal 
of the surgeon. Skillful management of complications 
when they do occur is the sine qua non of the wise and 
mature surgeon. 

The surgeon who anticipates a high probability of 
an unusual specific complication should inform the 
patient and explain the anticipated management and 
sequelae. Notation of this should be made in the 
informed consent that the patient signs. 

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