Complications of tooth extractions

1. Complication of mucosal time:

• Lip and tongue trauma (Protection of the scalpel blade by strip) 

• In the mandible: injuries to the lingual nerve during incision of the trigone (scalpel blade)
• Overly deep vertical vestibular discharge incisions can cause injury to the facial artery trunk, injury to V3 at its emergence from the mental foramen, and Wharton’s canal.
• In the maxilla: during the vertical discharge incision, damage to the stenum, Bichat’s fatty ball, may occur.
• Involvement of the tonsillar pillars🡪 is exceptional.
• Subcutaneous emphysema of the soft tissues of the cheek (rotating instruments), remains a benign accident without gravity.

NB: the practitioner should pay attention to the surrounding anatomical elements. 

2. Loss or fracture of instruments: 

This type of accident (rotating instrument in the tongue, in the gum or in the bone, tip of syndesmotome in the alveolus) is too often due to a handling error (ill-adapted or too brutal gesture). The patient must be informed of the event in order to hope for cooperation and the practitioner will try to recover the fragment of instrument.

In case of non-cooperation from the patient or anatomically difficult region, the procedure may be postponed to a later session. 

3. Complications of dental time:

1. Crown fracture  : Dilapidated, ankylosed teeth (non-serious accident), Inform the patient (to avoid sudden reflex movements). Remove the remaining fragment.
2. Fracture or mobilization of a neighboring tooth (tooth bearing a crown, decayed). Follow-up, namely reconstruction in the event of a crown fracture, endodontic treatment on request, if dental mortification 
3. Root denudation of a neighboring tooth following an alveolectomy
4. Fracture of an apex. If accessible, extract it with a syndesmotome or endocanal file, otherwise refrain from treatment

• Hence the importance of a preoperative X-ray assessment.
• Mastery of the gesture.
• Patient information.

5. Projection of a tooth out of its socket: following a poorly controlled maneuver, either the whole tooth or part of it.

• Projection into the digestive tract (minor accident): In this case, the patient swallows and swallows the fragment by reflex maneuver. Most often, this fragment or tooth follows the path of the food bolus and is evacuated naturally within 48 to 72 hours. There is a risk of the swallowed fragment becoming trapped: In the event of a risk of digestive complications, excision will be considered by endoscopic or surgical means.
•  Projection into the airways (serious accident)

Severe respiratory distress requires tooth expulsion maneuvers (HEIMLICH maneuver) and resuscitation methods while waiting for help to arrive.

Inhalation of a small dental fragment increases the risk of infection, requiring resuscitation in a specialist unit.

These first two complications are avoided under general anesthesia by the placement of an oropharyngeal pack.

• Projection into the cellular fatty spaces of the face:

Risk of infection (Cellulitis):

• Remove the tooth carefully if possible.
• Imaging supplement (Scanner)
• Sometimes just surveillance.
• Projection of a tooth into the maxillary sinus: 

Attempt immediate recovery via enlarged alveolar route (patient in sitting position + retro alveolar X-ray on site). In case of difficulty, avoid any persistence and postpone in better conditions (Caldwell-Luc type vestibular route).

• Projection of a maxillary wisdom tooth into the pterygomaxillary fossa:

Fortunately, this is rare. Given the difficulty of surgical access and the numerous vascular-nervous elements. In the absence of clinical signs, abstention and monitoring are the rule.

If infectious complications appear or in the presence of a TMJ disorder, or even nerve compression, surgical search for the tooth is necessary under general anesthesia.

• Projection of the maxillary wisdom tooth into the infratemporal fossa: Very rare, the patient is referred for maxillofacial surgery.
• Projection of the mandibular wisdom tooth into the floor of the mouth: following an untimely maneuver, this complication results from a fracture of the internal table.

Stop the act and orientation in Maxillofacial.

6. Extraction failed:

• Failure of anesthesia.
• Tooth error: most often premolars when an ODF extraction is indicated 
• Non-cooperation of the patient.
• The operation took too long due to an operative difficulty 
• Poor patient tolerance to the procedure (gag reflex)
• Complication of extraction of a baby molar: during the extraction of a baby tooth whose roots encase the germ, the latter can be extracted, it must be reimplanted immediately.

4. Bone complications:
5. Alveolar fracture: this is a fractured fragment of the alveolar wall whose etiology is related to:

• Weakened and demineralized bones in the elderly.
• Bone weakened by local infection.
• Poorly adapted maneuvers, poor support.
• Tooth stiffened in places 
• Resulting in:
  •  Exposure or even dislocation of adjacent teeth
  •  Lingual nerve injury (internal mandibular table)
• It is important to remove the fractured fragment

• Perform bone regularization using a bone rasp, gouge forceps or a rotating instrument under irrigation
• To prevent these complications: Perform gentle maneuvers.

2. Fracture of the tuberosity: during avulsion of the upper DDS revealed by:

• Localized hemorrhage
•  Cracking and free play of the fractured fragment.
•  Bone sequestrum stuck to the tooth
• Search for possible mobile fragments in the alveolus which must be carefully removed 
• Bone regularization
• Verification of sinus effraction (VALSALVA test)
• Mandible fracture: the classic fracture of the mandibular angle remains rare following extraction of the mandibular DDS, favored by:

•  Low inclusion
•  Uncontrolled dislocation
•  Excessive osteotomy
•  Large pericoronary cyst
•  Osteoporotic Weak Bones in the Elderly 

• The suggestive signs are of the cracking type with intense pain. 
•  Hemorrhage
• Articulation disorder.
• The course of action is to:
  •  A revision of the alveolus as well as a radiological control 
  • Ensure local hemostasis
  • A non-displaced fracture recommends a soft diet and radiological monitoring. 
  • A displaced fracture is the reduction of the fracture with contention or treatment by osteosynthesis 
•  Sometimes the fracture can go unnoticed during surgery and then manifests itself by pain and delayed healing, confirmed by radiological examination, then treated by osteosynthesis.

3. Bucco-sinus communications: follows the extraction of antral teeth, residual roots near the sinus. Inappropriate maneuvers and dislocation movements. Tuberosity fractures. 

The bucco-nasal communication follows the extraction of an ectopic tooth with a large pericoronal cyst.

      The positive diagnosis is manifested by:

• Positive Valsalva test (air bubbles in the alveolus)
• Careful exploration of the alveolus using a curette  
• Epistaxis may be observed inconsistently
• Fluid regurgitation through the nose 

The course of action is to: (close the CBS, which must be done immediately)

• Avoid untimely exploration
• Waterproof and hermetic sutures sometimes requiring bone plastic surgery 
• ATB coverage by general route 
• Avoid any hyperpressure maneuvers (sneezing, violent nose blowing), mouthwashes.
• Extemporaneous protective gutter in resin or silicone.
• In case of persistence of CBS with clinical signs:
  • Sensation of air leakage
  • Fluid passage through the nose
  • Purulent discharge with chronic sinusitis 
  • The closure of the CBS is done by transposition of a trapezoidal vestibular flap, palatal flap or even the transposition of the BICHAT fat ball with or without bone graft.

5. Joint complications:   temporomandibular dislocation can follow;

• A prolonged mouth opening.
• Application of excessive force.
•  Incorrectly placed orthostatic retractors.

• Manifests itself by a snap, irreducible condylar dislocation
• Limit openings that are too large.
• Reduction in case of dislocation (NELATON maneuver)
•  Rest and fit a chin sling to minimize jaw movements and prevent recurrence, regular liquid diet.
• Control and monitoring of developments.

6. Bleeding complications:

• Arterial or venous hemorrhage : Manifests itself by abnormal bleeding into the alveolus:
  •  In jet (Arterial)
  •  In sheet (Venous)
•  Origins:

• General etiology (Coagulopathies)
• Truncal anesthesia at the spine of Spix, 
• Mental hole (intravascular injection)
• Lower DDS (vascular-nervous pedicle injury)
• Injury to the branches of the internal maxillary artery during tuberosity fracture.
• Periapical lesions (granuloma or cyst)    

7. Nervous complications:

Inferior alveolar nerve injury: during avulsion of the mandibular DDS whose relationships with the inferior alveolar nerve are very close, we have either:

1. A simple bruise
2. Complete nerve section during tooth avulsion (rare)
3. Resulting in disturbances in the sensitivity of the hemilip (hypoesthesia) 
4. Sometimes manifests itself as electric discharges 
5. Or even by paresthesia or dysesthesia (tingling or burning sensation)
6. Anesthesia of the affected areas.

Lesion of the lingual nerve: during the incision, hence the importance of moving the incision line to the vestibular side, be careful of untimely movements in the region of the retromolar trigone.

Mental nerve injury: after significant mandibular bone resorption, occurs during anesthesia or during discharge incisions.

• There may be spontaneous healing (minor injuries)
• Medical treatment: (Group B vitamins – Corticosteroid therapy – Analgesics) 
• Microsurgical sutures (open wound)
• Short and long term monitoring.
•  Interest in in-depth radiological exploration before indicating the extraction of DDS
• If the indication requires it and the DDS is closely related to the mandibular canal, the Commissionat method is indicated here, which consists of cutting the crown and leaving the roots which will migrate towards the alveolar crest.

8. Post-operative complications:
9. Post-extraction hemorrhages: classically, the treatment of local hemorrhage involves three processes: 

1. Intrinsic compression:
   • Local hemostatic agents (surgisel, hemostatic sponges)
   • The sutures
2. Extrinsic compression:
   • Resin gutter
   • Optosil gutter
3. Alveolar revision.
4. Facial pain and aches:

• Relatively common complication
• Failure to comply with dosages and times of medication intake.
• Failure to follow post-operative advice.
• Traumatic accidents in the operated area.

       It is necessary to consider reassessing the current pain treatment:

• Mild to moderate pain: Paracetamol 1g every 6 hours.
• Severe pain: NSAIDs + Paracetamol + Codeine (Tramadol®)
• Patient motivation for treatment (+++)
• If persistence🡪 suspect neurological lesions and vascular pain.

3. Lockjaw : 

• Follows an avulsion of the lower DDS especially 
• Possibly indicative of a mandibular fracture. 
• General infectious causes (Tetanus, Meningitis) must be investigated.
• ATB treatment with symptomatic treatment
•  Mouth opening rehabilitation (Mechanotherapy-physiotherapy-thermotherapy)

4. Infectious accidents:

• The most frequent 
• Failure to comply with hygiene and asepsis conditions.
• Poorly adapted operating technique
• Pre-existing infection.
• Oral hygiene and patient cooperation 

Cellulite:

According to its form: Serous, purulent, circumscribed or diffuse, the etiology varied:

• Weakened terrain (immunodeficiency)
• Poorly conducted surgical phase
• Inadequate antibiotic therapy.
• Use of NSAIDs.

• Elimination of the infectious focus
•  Drainage in case of purulent collection.
• Broad spectrum ATB treatment (combination: Amoxicillin + clavulanic acid (Aungmentin®)
• Regular monitoring and follow-up

Alveolitis: Dry alveolitis: whose etiology:

• Surgical trauma
• Fibrinolysis abnormality destabilizing the clot.
• Untimely rinsing
• Check the emptiness of the alveolus (retroalveolar X-ray)
• Alveolar curettage under anesthesia without vasoconstrictor 
• Application of a eugenol-based dressing, repeatable until the pain disappears (Regression in 3-4 days)
• Antibiotic treatment + powerful painkillers.

Suppurative alveolitis.

• Superinfection of the clot and sometimes of the alveolus + Suppuration.
• Occurred more quickly (less than 24 hours)
• Less intense pain than dry socket.
• Fever and regional lymphadenopathy.
• Alveolus revision + curettage under anesthesia 
• Eugenol-based wick or (Alveolopenga®)
• Prevention: Systematic revision of the alveolus.

 Osteitis:

•  Rare
•  More common in the mandible.
•  Following untreated alveolitis, residual cyst.
• Favored by the terrain (irradiated bone, diabetes, etc.)
•  General condition impaired.
• The action to be taken is as follows:

•  The elimination of possible bone sequestra.
• Appropriate and prolonged antibiotic therapy.
• Osteoradionecrosis: bone sequestrum removal and repair

9. Remote complications:
10. Thrombophlebitis :

•  Venous inflammation with clot formation. 
• A real state of shock.
• Alteration of general condition
• Hospitalization of the patient , specialized care.
• Anticoagulant treatment + antibiotics.

2. Residual cyst: follows a granuloma whose excision was incomplete, is characterized by its slow and silent evolution. May be revealed by a triggering factor:

• Cellulitis following superinfection.
• Pathological fracture
• Maxillary sinus invasion
•  Surgical excision + regular check-ups.

Complications of tooth extractions

  Deep cavities may require root canal treatment.
Dental veneers correct chipped or discolored teeth.
Misaligned teeth can cause uneven wear.
Dental implants preserve the bone structure of the jaw.
Fluoride mouthwashes help prevent cavities.
Decayed baby teeth can affect the position of permanent teeth.
An electric toothbrush cleans hard-to-reach areas more effectively.
 

Complications of tooth extractions