Complications of Overview

Dentoalveolar Surgery
• Prevention
• Patient management
• Soft tissue injuries
David L. Basi DMD, PhD • Hard tissue injuries
ORAL and MAXILLOFACIAL • Post-operative complications
SURGERY
UNIVERSITY of MINNESOTA

Prevention
• Planning
• Know your limitations Injuries during surgery
• Know your patient/procedure
– medical status
– radiographs

Soft Tissue Injuries

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

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

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 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

Proper flap design

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

Torn Flap

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Tooth/Fragment in Sinus
• Careful inspection
• Radiographs
• Remove promptly if possible
Displaced or retained roots
Retained Root
• Rule: Uninfected root tips (< 2-3mm) left
within the bone have minimal
complications vs. destructive surgical
removal
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
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 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
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.
Oral - Antral Communications
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.
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
• 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.
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 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.
Sinus Membrane
Sinus Floor
Primary Closure
Sinus Precautions!
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.
Care of the Mouth Following
A-O Communication
• Sinus precautions include:
– No nose blowing, straw sucking, smoking
– Nasal decongestants, antibiotics
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 Evaluate Sinus
Prevention
Plan surgery:
Simple vs surgical extraction

Make a surgical plan:

Simple extraction

Look at the Radiograph! Sinus floor Have a surgical plan

•Simple vs surgical
•Section tooth
•Flap design

Increased risk for sinus exposu

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

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 Surgical Technique
• Sectioning of tooth
– Avoid excessive forces to bone and
adjacent teeth
– Reduce bulk of crown
– Split roots
– Purchase points

Hard Tissue Injuries

• Buccal bone fracture
• Tuberosity fracture
• Consider surgical extraction
• Management depends on periosteal
attachment

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 Fractures
Maxillary Tuberocity Fractures
Tuberosity fractures:
• If fracture of the tuberosity
occurs and the tooth is Mandible fractures:
asymptomatic and without
pathology, the extraction should • Mandibular fractures are a recognized
be deferred, and the tuberosity
should be immobilized with an
complication of third molar surgery and
arch bar for 6 weeks prior to should be listed on routine consent forms.
attempting removal.
• Predisposing conditions are: Mandibular
• If the tuberosity is only slightly
loose, discontinuation of the atrophy, osteoporosis, increased age and
procedure may be the only pathology such as cysts, growths or tumor.
treatment necessary.

Bleeding
• History/family history
Intra-operative bleeding • Medications
– ASA
– NSAIDS
– Coumadin
• Hypertension

Bone Wax:
(Salicylic acid and Beeswax)
Bleeding: Intraoral Factors
• Vascular
• Often open wound
• Loss of clot

Mechanism of action:
Mechanical blockage of small bone cannels

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 Bleeding: Management Bleeding: Prevention
• Pressure/patience • Atraumatic technique
• Injection • Curettage of granulation tissue
• Bleeding vessel
• Local anesthetic
• Hemostatic agent

Gauze
Hemostatic Agents

And……

Gelatin

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

Pressure, Pressure and more….

Pressure

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Suture
Collagen
Mechanism of Action:
Activates platelet aggregation
Bleeding: Hemostatic Agent
• Topical thrombin
– Stimulates fibrin formation
– Cannot use with surgicel (deactivates)
• Anti-fibrinolytic agents
– aminocaproic acid (Amicar)
– tranexamic acid
Microfibrillar Collagen
Mechanism of Action:
Activates platelet aggregation
Oxidized Regenerated Cellulose
Mechanism of Action:
Helps stabilize clot formation
(Does not activate coagulation
cascade or platelets
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
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 Postsurgical Sequelae

•Pain
Post-op complications •Swelling
•Bleeding
•Infection

Impacted Teeth Postsurgical Sequelae

• Incidence of complications 10% • Most common sequelae: PAIN
– Determine which analgesic(s) and how
• Predictable: Pain, Swelling, Bleeding, Trismus many to prescribed:
• Can last 3 to 5 days
• Common: Alveolar Osteitis, 6 to 12% • Bone removal (?)

• Rare: Nerve injury, jaw fracture – Strong consideration: Length of operation

Postsurgical Sequelae Alveolar Osteitis

“Dry Socket”
• Infection
– Ranging from 1.7% to 2.7% • Clinical presentation
– 50% occur 2 to 4 weeks post op – increasing pain post-op day 3 to 5
– Local, subperiosteal abcess – malodor
– pain not relieved by class III narcotic
– pain awakes at night
– radiates to ear.

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

Alveolar Osteitis Post-Operative Bleeding

“Dry Socket”
• Factors which reduce incidence
– prophylactic antibiotics (?)
– copious irrigation
– preoperative chlorhexidine rinse (50%)
– antibiotics in extraction site
• Risk vs. benefit

Removal of maxillary teeth

PO day 1

Liver clots

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

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 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
• 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.
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
• 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
• 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.
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 Cycle of Sinusitis

• Mucosal edema
• Stasis
• Inflammation and
Hyperplasia

Mucociliary Clearance Fistula Closure

• Two layered closure when possible
• Presence of preordained pathways to the ostia • Buccal flap
• Coordinated beating of cilia • Palatal flap
• Bypasses windows in the maxillary walls – posteriorly based
• Scar can form a barrier – anteriorly based
• Combination flaps
• Alloplastic materials

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 Oral-Antral Fistulas:
Conclusions
• If oroantral fistulas are small they may heal
spontaneously
• For persistent fistulas- control sinusitis, establish Nerve Injury
physiologic drainage
• Two layer closure when possible

Nerves at Risk in Dentistry

• 3rd division of CN V
– Inferior alveolar nerve
– Lingual nerve
– Mental nerve

Other nerves at risk in

Nerve Injury
dentistry
• Incisive nerve • Inferior alveolar nerve - 3% accepted
incidence reported
• Nasopalatine nerve • Paraesthesia to anesthesia -transient vs.
• Buccal nerve permanent
• Greater palatine nerve • Most common: MA or Vertical impaction

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 Seddon Classification of
Nerve Injury
Nerve Injury
• Lingual nerve with soft tissue reflection • Neuropraxia
-3% to 11.5% reported • Axonotmesis
• Neurotmesis

Descriptive Terms for Pain

Procedures with Risk
Response
• Allodynia • Implants
– Pain due to stimulus which normally does not cause pain
• Hyperesthesia • Apical surgery
– Increased sensitivity to stimulus
• Dysesthesia
• Periodontal surgical procedures
– Unpleasant abnormal sensation
• Anesthesia
– Absence of pain in response to stimulus that normally
causes pain

Procedures with Risk Procedures with Risk

• Local anesthetic injection • Surgical removal of mandibular third
• Flap elevation molars
• Biopsy of lower lip or vestibular region – inferior alveolar
– lingual
– buccal

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 Conventional Sensory Tests
• Map affected area
• Cold/warm
• Von Frey hairs/blunt
Indications for Nerve Repair
Conventional Sensory Tests
• Brush stroke direction
• Two point discrimination
• Needle-sharp
• Sensory evoked potentials
Nerve Repair
• Refer to specialist that treats nerve injuries
ASAP
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 Repair of IAN Injuries
• Nerve exploration and decompression
• Neurolysis
• Direct neurorrhaphy
• Interpositional nerve graft
• Nerve transfer

Extraction
socket Vicryl mesh/Lingual
Nerve

Prevention of Bacterial
Endocarditis (High risk)
• Prosthetic cardiac valves
Antibiotics • Previous bacterial endocarditis
• Complex cyanotic congenital heart
disease
• Surgically constructed systemic
pulmonary shunts or conduits

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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
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