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Post operative complications and their management

Oral surgery presentation
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Mona Shah

on 15 July 2013

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Transcript of Post operative complications and their management

POST OPERATIVE COMPLICATIONS AND THEIR MANAGEMENT
Complications of Dental Implants
Complications after Extraction of Third Molars
Post Operative complication of Anesthesia
ORAL SURGERY PROCDEURES
EXTRACTION - Single, multiple, uncomplicated, and complicated
EXTRACTION OF THIRD MOLARS
BIOPSY FOR PATHOLOGY
FRENECTOMY - ankyloglossia (or tongue tie) and removal of upper lip frenums
APICECTOMY - removal of infected root tip after root canal treatment
PRE- PROSTHETIC SURGERY – multiple teeth extractions, bone modifications, and soft tissue removal prior to denture construction
TREATMENT OF DENTAL INFECTIONS
PERIODONTAL SURGERY
DENTAL IMPLANTS
ORTHODONTIC EXPOSURE OF IMPACTED TEETH
SINUS LIFT
COMPLICATIONS OF TORI REMOVAL

Immediate or late fracture of the mandible is a Rare event.
Major complication.
The reduction of bone strength may be caused by
Physiologic atrophy
Osteoporosis
Pathologic processes
Can be secondary to surgical intervention
Incidence not clearly understood.
Libersa et al. found an incidence of 0.0049%
In a study by Arrigoni & Lambrecht, 3980 third molar removals were analyzed.This group detected a complication rate of about 0.29 percent. The peak incidence occurs in patients over 25 years, with a mean age of 40 years.
Due to a greater masticatory force, men may be more likely to have late fractures.
Intraoperative fractures may occur with improper instrumentation and excessive force to the bone during tooth removal.
Most late fractures occur between two to four weeks after surgery during masticating.

Unusual Inflammatory processes and Abscess formation:
In the reviewed case reports, extensions of the inflammatory processes to atypical regions of the brain and cervical region are discussed.
CASE #1
A subperiosteal abscess of the orbit appeared in a 57-year-old man following the uneventful extraction of the left maxillary third molar which might have been caused by extension of infection via the pterygopalatine and infratemporal regions to the inferior orbital fissure.

CASE #2
Epidural abscess of a 20-year-old woman after extraction of a wisdom tooth.First, she was diagnosed with a musculoskeletal neck sprain resulting from posture during the operation. Three days later, the patient presented with an increased right-sided neck pain and sensational numbness to the right arm. Nine days after surgery, an epidural abscess to the right side of C4/C5 vertebrae was seen in the MRI.
CASE # 3
A 21-year-old man had all four third molars removed. presents a subdural empyema and herpes zoster syndrome (Hunt syndrome) An abscess involving the right pterygomandibular and submasseteric spaces and extending to the infratemporal fossa was found.
Although antibiotic therapy and drainage was initiated, he developed severe frontal headache and vomiting with a Glasgow coma score of 13. (a scale that determines the consiousness and nuerological scale of the patient under assessment)

Magnetic resonance imaging (MRI):
showed a subdural collection in the right temporoparietal region.
He had emergency craniotomy and subdural drainage.

< 9 severe
9-13 moderate
> 13 minor
CASE # 4
A brain abscess developed after removal of the right lower third molar of a 26-year-old man.
He needed emergency neurosurgery and antibiotic treatment for eight weeks.
MINOR/ CHAIRSIDE PROCEDURES
Procedures that a patient may be referred to an OMFS for are:
Complicated extractions and wisdom teeth extractions
Implants
Maxilla and Mandible osteotomies and orthognathic surgery
Sinus lifts
Reconstructive/ cosmetic surgery
Orthognatic surgery
TMJ surgery
Cancer diagnosis and surgery
Congenital malformation surgery such as cleft lip/palate
CranioMaxillofacial Trauma surgery: trauma to the jaws and face such as mandible, cheek bone, and eye socket fractures
Diagnosis and treatment of facial pain, oral pathology, oral cancer.
TMJ surgery.
ORAL AND MAXILLOFACIAL SURGERY
General Anesthesia
Local Anesthesia
Regional Anesthia
Nitrous Oxide Sedation
IV sedation
General Anesthia
Pain
Nausea and vomiting - up to 30% of patients
antiemetics.
avoid using morphine like pain killers
Drowsiness
Damage to teeth - 1 in 4,500 cases
mouth-guards and bite-blocks
Sore throat and laryngeal damage
chose a smaller size for the device used to help you breath during surgery.
strepsils.
anti-inflammatory.
hypothermia
try to reduce the drop in body temperature
few drugs to treat post-operative shivering.
tramadol, magnesium sulfate, αalpha 2-agonists (eg, clonidine and dexmedetomidine), physostigmine, doxapram, methylphenidate, and 5-HT3 antagonists.
Pain - 25% of patients still experience pain despite spinal anaesthesia
seizures
unconsciousness
cardiac rhythm abnormality with cardiac collapse
soreness at the injection site
bleeding/hematoma/bruising at the injection site
large swellings that look like hives on the skin, in the mouth, or in the throat
nerve damage
An incomplete or failed block
severe headache

Pain
Allergy
Bleeding and haematoma formation
Nerve injury due to direct injury
Infection
Ischaemic necrosis
Anaphylaxis to anaesthetic agents - figures such as 0.2% have been quoted
Cardiovascular collapse
Respiratory depression
Aspiration pneumonitis - up to 4.5% frequency has been reported; higher in children
Hypoxic brain damage
Nerve injury - 0.4% in general anaesthesia and 0.1% in regional anaesthesia
Awareness during anaesthesia - up to 0.2% of patients; higher in obstetrics and cardiac patients
Embolism - air, thrombus, venous or arterial.
Backache
Headache
Idiosyncratic reactions related to specific agents, eg malignant hyperpyrexia with suxamethonium, succinylcholine-related apnoea
Iatrogenic, eg pneumothorax related to central line insertion
Death
Regional Anesthesia
Local Anesthesia
blurred or double vission
dizziness or lightheadedness
drowsiness
confusion
anxiety, excitement, nervousness, or restlessness
feeling hot, cold, or numb
ringing or buzzing in the ears
shivering or trembling
sweating
pale skin
slow or irregular heartbeat
breathing problems
nusual weakness or tiredness
Displacement of third molars and instruments
Upper third molars can be displaced into
the infratemporal fossa.
submandibular space
sublingual space
pterygomandibular space
the lateral pharyngeal space
into the lateral cervical area.
In one case, the symptoms started after two months. The patient experienced recurrent inflammatory swelling in the right submandibular space.
Over a period of 14 months, the same dentist supervised treatment with antibiotics. After extensive imaging procedures and surgery. the tooth was located beneath the platysma muscle.
Parts of dental equipment or burs can also be lost in the adjacent tissues.
A 35-year-old woman had severe trismus, swelling, and pain three weeks after removal of tooth 48.
A 20 mm long diamond bur was found in the submandibular space.
uncommon
either a root fragment, the crown, or the entire tooth
Displacement of mandibular teeth/roots usually occurs when it is located lingually, or when the lingual cortical plate is fenestrated and if surgical technique is poor.
When a root fragment "disappears" during extraction, its retrieval should not be attempted unless from a specialist
Permanent inferior alveolar or lingual nerve damages is extremely rare,
Most common causes of litigation in dentistry.
Due to Close anatomic relationship
The incidence of PERMANENT Inferior alveolar nerve lesions ranges from 0 - 0.9 %; the usual accepted rate is about 0.3 %.
The complication rate for TEMPORARY lingual nerve damage is around 0.4 % and for PERMANENT lingual nerve damage, it is even lower.
Permanent nerve damage
Post Traumatic Nerve problems
Distorted sensation
Parasthesia
anesthesia
Dysesthesia
itchy
Phantom sensations
Impaired funtion
chewing
speech
sleep
Pain
neuropathies
Management of Inferior Alveolar nerve injury

1.SURGICAL
INTERVENTION
If a damaged nerve segment has to be excised, repair by stretching the ends under slight tension is better than grafting.
If a graft is essential, a frozen skeletal muscle autograft is as good as a sural nerve graft
and avoids donor
site morbidity.
2.ENHANCING REGENERATION:
Incorporation of growth factors at a site of nerve repair can preferentially enhance the regeneration of specific groups of nerve fibres.
3.REDUCING INJURY INDUCED PAIN
A single case report by Goshlasby et al., discussed the development of a right sided retrobulbar hemorrhage after the removal of an impacted maxillary right third molar.
The resulting hematoma caused right periorbital swelling and ecchymosis with evidence of proptosis.
The maxillary incision was extended and the hematoma was drained and bleeding was controlled. It was believed that a branch of the posterior superior alveolar artery was injured during the extraction and bleeding tracked into the orbit via the infra-orbital fissure. Severe intraoperative or postoperative hemorrhage is one of the few life threatening complications in which a dentist may have to initiate management.
Common Complications
Alveolititis Sica
Also known as DRY SOCKET
Is defined as inflammation in the socket of a tooth
Occurs 3-4 days after tooth is extracted
Due to the failure of blood clot to form or its dislodgement leaving bone and nerve exposed to air, food and fluids.
Mandiblular molars, Especially third molars
Signs and Symptoms
Extremely Painful socket with readiating pain
Foul smelling (Halitosis)
Bloodless socket
Inflammation
Differential diagnosis is osteomyelitis.

Surgical revision under local anesthesia to remove the necrotic tissue and creating fresh wound surfaces
Advice warm saline rinse to remove food debris.
Guaze with the disinfectant can be soaked and kept in the socket
Zinc oxide dressings also have been advised, commercial dressings are also available:
Alvogyl
Dressol-X
D.S. Dressing/paste
Analgesic drugs
may take several weeks to heal completely



Insufficient blood supply to the alveolus.
Preexisting infection. (Granuloma, periodontal or pericoronal infection)
Use of large amounts of local Anesthetic, leading to vasoconstriction.
Post operative bleeding.
Trauma to alveolus during extraction.
Infection during or after extraction.
Root/bone fragments or foreign bodies left in the socket.
Excessive irrigation and curettage.
Loss of clot due to patient's negligence
Patient actions like sucking liquids, sneezing, coughing, rinsing water post extraction
Predisposing factors in patient, eg smoking, poor general health


CAUSES
MANAGEMENT
INFECTIONS
Patient presents with:
Abcess
Purulent secretions
Pain in post extrection socket.
Trismus
Pre-disposing factors
Poor oral Hygiene
Presence of pathological processes during extraction (chronic perichronitis), agressive procedure and deep impaction
TREATMENT
Local and Systemic Antibiotics
Oral antimicrobial lavage
Post operative hemorrhaging accurs during the first 24hours of surgery.
- Prolonged/ excessive bleeding
Systemic/ inherited coagulation disorders
Thrombocytopenia
Heamophilia
Von willebrand disease,
Rare coagulation factor deficiencies
and various platelet disorder
Drug induced platelet defects
- Successful treatment relies on good history and preventive measures


MANAGEMENT for Primary Bleed
Socket should be properly cleaned. If bleeding arteries exist in the soft tissue, control with direct pressure by claming and eventual ligation with resorbable suture.
If no arteries exist in the extraction field,
squeeze the socket
complete hemostatic control can usually be maintained for most procedures by using direct pressure over the area of the soft tissue for approximately five minutes.
The socket should be covered with a damp 2x2 inch gauze sponge that ahs been folded to fit directly into the extraction site.
The patient should be instructed to bite down firmly on this damp gauze sponge for at least 30 minutes. check socket 15minutes after the surgery.


Hemostatic Agents
Absorbable gelatin sponge (Gelfoam, Pfizer).
Gelfoam sterile compressed sponge is a pliable surgical hemostat prepared for specially treated purified gelatin solution.
It is capable of absorbing and holding within its meshes many times its weight in whole blood.
It is designed to be inserted in the dry state, and functions wonderfully as a hemostatic agent.
sued to aid in primary closure for large extraction sites
placed into the socket and retained with a suture.
Oxidized regenerated methylcellulose (Surgicel, Johnson and Johnson)
It binds platelets and chemically precipitates fibrin.
Topical thrombin (Thrombostat, Pfizer) is derived from bovine thrombin (5,000 units).
Thrombin bypasses all steps in the coagulation cascade and helps to convert fibrinogen to fibrin which forms the clot.
Inserted into the tooth socket when needed.

BLEEDING
Secondary bleeding
covered with a folded, damp gauze sponge and aplly pressure for 5mins.
give anesthesia preferably block
gently curette the tooth extraction socket and suction all areas of the old blood clot
Ecchymosis may accur (elderly).
Reducing trauma is the best way to prevent ecchymosis. Moist heat may be applied to speed up the recovery.
An electron micrograph of human lingual nerve damaged during third molar removal, showing axonal exposure (arrowheads) and apposition (arrows) of unmyelinated nerve fibres.
Radix in Antro Highmori
The radixes of upper third molar can extend into the antral cavity.
that is why radix or even the whole tooth can be pushed into maxillary sinus especially after a traumatic surgery

MANDIBULAR FRACTURES
UNUSUAL INFLAMMATORY PROCESSES AND ABCESS FORMATION
Complication #1 - Dental implant infection
Complication #2 - Dental implant rejection
Complication #3 - Dental Implant overload
Complication #4 - Dental implant failure
Complication #5 - Dental implant bone loss
Complication #6 - Dental implant inflammation
Complication #7 - Dental implant incision line opening
Hemorrhage
Inferior Alveolar Nerve injury
injury of adjacent tooth by a malpositioned implant.
Wound dehiscence - surgical complication in which a wound ruptures along surgical suture.
Maxillary sinus lift
maxillary sinitis
Fracture of mandible
deviation of other teeth
Sublingual Hematoma
Hematoma
Wound infection
Flap necrosis
paresthesia
Fibrous scar formation
Recurrence of the lesion.
COMPLICATONS OF MUCOCELE EXCISION
Bleeding
Infection
Accidental damage to other teeth and your jaw during your operation
Numbness in your lower lip or tongue, or changes to taste - this can be caused by nerve damage and there is a small chance that this could be permanent
Jaw stiffness - it's possible that you may not be able to open your mouth fully for a while.
COMPLICATIONS OF CYST EXCISION
REFERENCES
1.http://www.bmj.sk/2010/11105-11.pdf

2.By: Hans Ulrich Brauer, DDS, Dr Med Dent, MA; Robert A. Green, DDS, MD, Msc, FRCD(C); Bruce R. Pynn, Ms
2013-06-01
http://www.oralhealthgroup.com/news/complications-during-and-after-surgical-removal-of-third-molars/1002368229/

2.Munoz-Guerra MF, et al. Subperiosteal abscess of the orbit: an unusual complication of the third molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:9-13

3.Ramchandani PL, et al. Subdural empyema and herpes zoster syndrome (Hunt syndrome) complicating removal of third molars. Br J Oral Maxillofac Surg 2004;42:371.

4.Burgess BJ. Epidural abscess after dental extraction. Emerg Med J 2001;18:231

5.Revol P, et al. Brain abscess and diffuse cervico-facial cellulites: complication after third molar extraction. Rev Stomatol Chir Maxillofac 2003;104:285-289.

6. Yalcin S, et al. Accidental displacement of a high-speed handpiece bur during mandibular third molar surgery: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;105:29-31.

7. http://www.patient.co.uk/doctor/important-complications-of-anaesthesia

8. Gay-Escoda C, et al. Accidental displacement of a lower third molar. Report of a case in the lateral cervical position. Oral Surg Oral Med Oral Pathol 1993;76:159-160.

9.http://www.sheffield.ac.uk/dentalschool/research/ibio/neuroscience/injuries

10.http://www.healthmantra.com/hctrust/dry_socket.shtml

11.http://www.dkku.net/topic/1247-etiology-prevention-and-management-of-post-extraction-complications/

12.http://www.atlantadentalimplants.com/dental_implant_complications.html

13.http://www.intechopen.com/books/implant-dentistry-a-rapidly-evolving-practice/clinical-complications-of-dental-implants

15.http://loveperio.com/2012/08/29/sinus-lift-maxillary-sinus-augmentation/
Made by: Mona Shah
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