1

Complications of Dentoalveolar Surgery

David L. Basi DMD, PhDORAL and MAXILLOFACIAL

SURGERYUNIVERSITY 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

2

Patient Management

• No surprises – informed consent

• Tell – communication

Prevention of soft tissue injuries

3

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

Torn Flap

4

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

• 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

5

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.

6

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 Membrane

Primary Closure

Sinus Precautions!

Care of the Mouth Following A-O Communication

• Sinus precautions include:– No nose blowing, straw sucking, smoking– Nasal decongestants, antibiotics

7

Prevention

Plan surgery:Simple vs surgical extraction

Evaluate Sinus

Make a surgical plan:Simple extraction

Look at the Radiograph! Sinus floor

Increased risk for sinus exposu

Have a surgical plan

•Simple vs surgical•Section tooth •Flap design

Surgical Technique

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

8

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

9

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

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: Intraoral Factors

• Vascular• Often open wound• Loss of clot

Bone Wax:(Salicylic acid and Beeswax)

Mechanism of action:Mechanical blockage of small bone cannels

10

Bleeding: Management

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

Bleeding: Prevention

• Atraumatic technique• Curettage of granulation tissue

Hemostatic AgentsGauze

And……

Pressure, Pressure and more….

Pressure

Gelatin

Mechanism of Action:Helps stabilize clot formation

(Does not activate coagulation cascade or platelets

11

SutureMicrofibrillar Collagen

Mechanism of Action:Activates platelet aggregation

Collagen

Mechanism of Action:Activates platelet aggregation

Oxidized Regenerated Cellulose

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

12

Post-op complications

Postsurgical Sequelae

•Pain•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 (?)

– 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

• 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.

“Dry Socket”

13

Alveolar Osteitis

• Patients at risk– females on oral contraceptives– smokes– Length of procedure

“Dry Socket”

• Factors which reduce incidence– prophylactic antibiotics (?)– copious irrigation– preoperative chlorhexidine rinse (50%)– antibiotics in extraction site

• Risk vs. benefit

“Dry Socket”Alveolar Osteitis Post-Operative Bleeding

Removal of maxillary teeth

PO day 1

Liver clots

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

14

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…continuedFistula Formation

• Causes– most common iatrogenic

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

• Fistula < 5 mm may close spontaneously

15

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

16

17

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

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

18

Nerve Injury

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

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

19

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

Indications for Nerve RepairNerve Repair

• Refer to specialist that treats nerve injuries ASAP

20

Repair of IAN Injuries

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

Extraction socket Vicryl mesh/Lingual

Nerve

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

21

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

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

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

• 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