COMPLICATIONS OF TOOTH EXTRACTIONS
Introduction :
There are several pre-, per- and post-operative complications secondary to dental extractions (anesthetic time and dental extraction).
It is possible to avoid these unforeseen events with appropriate techniques and a good assessment of the possible risks.
They can occur before, during or after tooth extraction. They are described:
- Complications related to the anesthesia stage.
- Complications related to the avulsion itself.
Problematic :
Number of possible complications in the dental office
Goals :
- Know and be able to diagnose pre, per and post-operative complications.
- Being able to take care of its complications.
PLAN
Introduction
I-Complications related to dental anesthesia
- I-1. Local complications
- I-2. General (systemic) complications
II-Complications of tooth extraction
- II-1. Immediate complications
- II.1.1 Dental complications
- a. Dental dislocations
- b Coronal dental fractures
- c. Root dental fractures
- d. Complications of adjacent teeth
- e. Projection of a tooth out of its socket:
- f. Extraction failed
- II.1.2. Mucosal complications
a. Bone complications
b. Oro-sinus communication
c. Hemorrhagic complications
II-2. Delayed (secondary) complications:
a. Soft tissue complications Cellulite
b. Hard tissue complications Alveolitis
c. Nervous accidents
- Complications of local anesthesia in dentistry
Divided into two groups:
– Local complications: frequent and most often without consequences.
– General or systemic complications: rarer but which can put the patient’s life at risk.
I.1. Local complications
I.1.1.Painful injection
The causes
- Injection speed too fast,
- Solution temperature too cold,
- nerve damage,
- unsuitable needle type
Prevention
- Establish a good relationship with the patient,
- Perform contact anesthesia,
- Heat the cartridge,
- Inject slowly,
- Inject at a distance from the source of infection,
- Avoid infiltrating a foramen.
I.1.2 Needle breakage
The causes:
- Manufacturing defect,
- Technical error by the practitioner,
- Sudden movement of the patient
Prevention
- do not perform multiple injections with the same needle,
- do not bend the needle more than once,
- do not insert the needle beyond its curvature,
- do not change direction without partially withdrawing the needle,
I.1.3 Nerve injury:
The causes:
- Direct nerve trauma, notably facial paralysis (following truncal anesthesia at the Spix spine ),
- following a hematoma or edema.
Prevention
- Respect maxillofacial anatomy.
The conduct to adopt:
- Record the event in the patient’s file,
- establish a follow-up over time to judge the evolution,
- Prescribe: steroidal anti-inflammatory drugs and vitamin B1, B6, B12,
- If the problem persists, you can refer the patient to a neurologist.
I.1.4 Lockjaw.
- Muscle trauma causing edema
- Hematoma,
- Infection.
Prevention:
- Respect protocols, asepsis rules and anesthetic techniques.
I.1.5 Soft tissue injury.
The causes:
- Prolonged anesthesia → involuntary biting of the lips; tongue (children and disabled people +++).
- Anesthesia of optimal duration depending on the procedure to be performed,
Prevention:
- Place a cotton roll between your lip and teeth,
- Prefer intraosseous anesthesia.
I.1.6 Irritation or ischemia of the oral mucosa
The causes:
- Topical application of surface anesthetic,
- Excess of vasoconstrictors,
- Injection pressure too high,
- Anesthetic temperature too cold.
Action to take:
- Prescribe a mouthwash as well as an antiseptic and healing ointment.
Prevention:
- Respect the terms of use and dosage of topical agents and vasoconstrictors,
- Warm the anesthetic solution,
- Do not inject too quickly or under high pressure,
I.2. General or systemic complications:
I.2.1 Vagal malaise . This is a malaise that can be attributable to excessive activity of the parasympathetic nervous system or to a decrease in activity of the sympathetic nervous system.
Clinic:
- bradycardia,
- low blood pressure,
- brief partial (lipothymia) or total (syncope) loss of consciousness.
The signs suggestive of this type of discomfort are perceived either:
- By the practitioner who may perceive pallor and sweating
- By the patient who feels like he is going to lose consciousness.
He has dizziness, a weak pulse, hot flashes, nausea and confusion.
visual (spots, veil before the eyes)
I.2.2 Allergic reactions . Allergic reactions represent all manifestations of hypersensitivity of the body after ingestion, injection, inhalation or contact with certain substances. They can manifest themselves:
- locally: skin allergy such as urticaria
- locoregional: skin and mucosal allergy such as Quincke’s edema
- general: this is anaphylactic shock, which corresponds to a type I allergic reaction, following exposure to an allergen, to which the patient is sensitized; This induces the release of inflammatory mediators including histamine.
The circumstances of occurrence are multiple:
- When using latex, especially gloves. This allergy is often combined with a food allergy (kiwi, banana, etc.)
- When administering iodinated contrast media
- When ingesting drugs such as penicillin, analgesics (acetylsalicylic acid, morphine, etc.), certain general or local anesthetics such as the ester group.
The clinical diagnosis is based on various manifestations:
- Sudden onset and rapid progression of multiple symptoms such as hives, erythema and/or swelling of the skin or mucous membranes (angioedema).
- Airway involvement: swelling of the tongue/throat, hoarse voice, etc.
- Impairment of one or more functions: Ventilation: wheezing, shortness of breath
- tachypnea, cyanosis…
- Circulation: pallor, tachycardia, hypotension…
- Complications of tooth extraction:
II.1 Immediate complications:
II.1.1. Dental complications:
a- Fracture of the tooth to be extracted follows:
- A defect in tooth dislocation.
- Ankylosed tooth.
- Crown weakened by decay or by a large filling.
b-Apex fracture:
More frequent, during extraction of a tooth that has been pulpless for a very long time due to ankylosis, or in the presence of a particularly resonant apex (angled apex, divergent roots)
Action to take:
- Check the integrity of the roots after any extraction
- Rinse the alveolus
- If the apex is easily accessible and mobile, it will be extracted with an appropriate instrument
- If it is deeply buried and not mobile: therapeutic abstention and resume extraction later
c- Fracture and mobilization of the adjacent tooth: This follows an ill-adapted maneuver during extraction, its crown may fracture, a reconstruction may be damaged.
d-Fracture of the antagonist tooth : This may be due to movement of the forceps, or to an uncontrolled extraction movement.
e-Projection of a tooth out of its socket:
- In a poorly controlled maneuver, part or all of the tooth can be propelled out of its socket and escape the operator’s control.
The locations can be of various orders:
- Projection into the digestive tract
- Projection into the airways
- Projection into the cellular-fatty spaces of the face
- Projection of a maxillary tooth into the maxillary sinus
- Projection of a maxillary wisdom tooth into the pterygomaxillary fossa
f- Extraction failed:
May be due to several elements:
- Failure of anesthesia
- Tooth error
- Poor patient tolerance to the procedure
- The intervention took too long
What to do
- Stop the gesture
- Premedication
- Radiological examination
- Resume extraction under better conditions.
II.1.2. Mucosal complications:
The mucosa can be damaged during the different extraction stages, so perforation, tearing and laceration can occur following instrument slippage caused by:
- Difficult anatomical and physiological conditions (trismus).
- Uncontrolled movements and reactions of the patient.
- Improper use of instruments: lack of support points.
- Lip trauma following prolonged traction on the lip commissure using the retractor, or prolonged use of rotating instruments.
II.1.3. Bone complications
- Fracture of the alveolar rims:
These are most often fragments of fractured, dislocated alveolar walls; they can be significant and affect sections of neighboring teeth.
- Fracture of the maxillary tuberosity :
Due to insufficient bone trepanation or dislocation movement too far back. Clinic:
- Hemorrhage.
- Tuberosity mobile or adherent to the tooth.
- Mandibular fracture : More common in:
- extraction of an impacted tooth (low impaction)
- excessive osteotomy (bone clearance)
- poorly controlled dislocation movement
- avulsion in the elderly
- in the presence of a large pericoronary cyst.
stop
- Sinus complications:
- Collapse of the sinus floor,
- Partially intra-sinusal tooth (antral teeth),
- Clumsy curettage,
- Fracture of the tuberosity.
- Positive Valsalva test.
- Hemorrhagic complications:
- Due to a deep incision, or a mutilating posterior release.
Arterial or venous bleeding:
- Arteriolar bleeding in a “jet” or venous bleeding in a “sheet” may be observed.
- Inferior alveolar artery involvement is a rare complication that can occur with a low impacted wisdom tooth.
II.2 Secondary complications:
- Bleeding complications:
These are delayed hemorrhages.
Causes:
– Adrenaline-related vascular vasodilation.
– Failure to correctly apply local hemostasis procedures.
– Failure to follow post-operative advice.
– Improper curettage after tooth extraction.
– Unidentified general pathologies
Action to take:
Research and elimination of the etiology in question
- b- Infectious complications:
- – Soft tissues:
- Jaw cellulitis comes in different forms (circumscribed cellulitis or diffuse cellulitis).
- – Bone tissues
Alveolitis: This is the inflammation of the dental socket after an extraction.
Alveolitis is always of infectious origin
There are two types of dry socket:
- Suppurative alveolitis; an infection of the tooth socket may occur a few days to a few weeks after extraction. Clinically characterized by throbbing pain with the presence of suppuration at the level of the socket, sometimes deterioration of the general condition
- Dry socket; an infection without pus can occur a few days after an operation characterized by an empty socket with lancinating pain.
Osteitis of the jaws:
Osteitis is an inflammatory disease of bone tissue. The causes of osteitis in the jaws are essentially microbial and local, particularly dentoalveolar. Clinical polymorphism is significant: the majority of forms are localized but there are diffuse forms.
- Nervous accidents
1. Inferior alveolar nerve
- A shot during anesthesia
- Trauma during dislocation
- Canal breakage during tooth fragmentation
- Postoperative edema causing compression
- Presence of a fragment of a fractured and forgotten instrument near the canal
2-Lingual nerve
- Accidental needlestick during anesthesia,
- Syndesmotomy too pressed on the lingual side,
- Internal table sequestrectomy,
- Lingual approach with insufficient nerve protection.
3. Mental nerve
- Needle prick
- Instrument slippage
- Poorly controlled mucosal incision
Conclusion
– Management of complications of anesthesia and dental extraction should be done calmly and with the necessary measures taken.
– Prevention remains the best way to avoid the genesis of these complications.
– If these complications appear, the operator must be sufficiently armed to avoid mishaps which can sometimes be unfortunate.
COMPLICATIONS OF TOOTH EXTRACTIONS
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