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21/Feb/2011

Complications of dental extraction

Infection: Although rare, it does occur. The dentist may opt to prescribe antibiotics pre- and/or post-operatively if they determine the patient to be at risk.

Prolonged bleeding: The dentist has a variety of means at their disposal to address bleeding; however, it is important to note that small amounts of blood mixed in the saliva after extractions are normal, even up to 72 hours after extraction. Usually, however, bleeding will almost completely stop within eight hours of the surgery, with only minuscule amounts of blood mixed with saliva coming from the wound. A gauze compress will significantly reduce bleeding over a period of a few hours.

Swelling: Often dictated by the amount of surgery performed to extract a tooth (e.g. surgical insult to the tissues both hard and soft surrounding a tooth). Generally, when a surgical flap must be elevated (i.e. and the periosteum covering the bone is thus injured), minor to moderate swelling will occur. A poorly-cut soft tissue flap, for instance, where the periosteum is torn off rather than cleanly elevated off the underlying bone, will often increase such swelling. Similarly, when bone must be removed using a drill, more swelling is likely to occur.

Sinus exposure and oral-antral communication: This can occur when extracting upper molars (and in some patients, upper premolars). The maxillary sinus sits right above the roots of maxillary molars and premolars. There is a bony floor of the sinus dividing the tooth socket from the sinus itself. This bone can range from thick to thin from tooth to tooth from patient to patient. In some cases it is absent and the root is in fact in the sinus. At other times, this bone may be removed with the tooth, or may be perforated during surgical extractions. The doctor typically mentions this risk to patients, based on evaluation of radiographs showing the relationship of the tooth to the sinus. It is important to note that the sinus cavity is lined with a membrane called the Sniderian membrane, which may or may not be perforated. If this membrane is exposed after an extraction, but remains intact, a “sinus exposed” has occurred. If the membrane is perforated, however, it is a “sinus communication”. These two conditions are treated differently. In the event of a sinus communication, the dentist may decide to let it heal on its own or may need to surgically obtain primary closure—depending on the size of the exposure as well as the likelihood of the patient to heal. In both cases, a resorbable material called “gelfoam” is typically placed in the extraction site to promote clotting and serve as a framework for granulation tissue to accumulate. Patients are typically provided with prescriptions for antibiotics that cover sinus bacterial flora, decongestants, as well as careful instructions to follow during the healing period.

Nerve injury: This is primarily an issue with extraction of third molars, but can occur with the extraction of any tooth should the nerve be close to the surgical site. Two nerves are typically of concern, and are found in duplicate (one left and one right): 1. the inferior alveolar nerve, which enters the mandible at the mandibular foramen and exits the mandible at the sides of the chin from the mental foramen. This nerve supplies sensation to the lower teeth on the right or left half of the dental arch, as well as sense of touch to the right or left half of the chin and lower lip. 2. The lingual nerve (one right and one left), which branches off the mandibular branches of the trigeminal nerve and courses just inside the jaw bone, entering the tongue and supplying sense of touch and taste to the right and left half of the anterior 2/3 of the tongue as well as the lingual gingiva (i.e. the gums on the inside surface of the dental arch). Such injuries can occur while lifting teeth (typically the inferior alveolar), but are most commonly caused by inadvertent damage with a surgical drill. Such injuries are rare and are usually temporary, but depending on the type of injury (i.e. Seddon classification: neuropraxia, axonotmesis, & neurotmesis), can be prolonged or even permanent.

Displacement of tooth or part of tooth into the maxillary sinus (upper teeth only). In such cases, almost always the tooth or tooth fragment must be retrieved. In some cases, the sinus cavity can be irrigated with saline (antral lavage) and the tooth fragment may be brought back to the site of the opening through which it entered the sinus, and may be retrievable. At other times, a window must be made into the sinus in the Canine fossa–a procedure referred to as “Caldwell luc”.

Dry socket (Alveolar osteitis) is a painful phenomenon that most commonly occurs a few days following the removal of mandibular (lower) wisdom teeth. It is commonly believed that it occurs because the blood clot within the healing tooth extraction site is disrupted. More likely,alveolar osteitis is a phenomenon of painful inflammation within the empty tooth socket because of the relatively poor blood supply to this area of the mandible (which explains why dry socket is usually not experienced in other parts of the jaws). Inflamed alveolar bone, unprotected and exposed to the oral environment after tooth extraction, can become packed with food and debris. A dry socket typically causes a sharp and sudden increase in pain commencing 2–5 days following the extraction of a mandibular molar, most commonly the third molar. This is often extremely unpleasant for the patient; the only symptom of dry socket is pain, which often radiates up and down the head and neck. A dry socket is not an infection, and is not directly associated with swelling because it occurs entirely within bone — it is a phenomenon of inflammation within the bony lining of an empty tooth socket. Because dry socket is not an infection, the use of antibiotics has no effect on its rate of occurrence. The risk factor for alveolar osteitis can dramatically increase with smoking after an extraction.

Bone fragments Particularly when extraction of molars is involved, it is not uncommon for the bones which formerly supported the tooth to shift and in some cases to erupt through the gums, presenting protruding sharp edges which can irritate the tongue and cause discomfort. This is distinguished from a similar phenomena where broken fragments of bone or tooth left over from the extraction can also protrude through the gums. In the latter case, the fragments will usually work their way out on their own. In the former case, the protrusions can either be snipped off by the dentist, or eventually the exposed bone will erode away on its own.


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20/Feb/2011

Complex Extraction

Unfortunately, not all extractions can be done by simply grasping the tooth with forceps and rocking it out.  What if there is nothing left above the gum line to grasp? Or what if the crown breaks off leaving the roots still in the bone? These things can and do happen, and any dentist that extracts teeth will have to deal with them routinely.

Retain Root

In these cases, it becomes necessary to surgically remove the tooth.    This is frequently accomplished by prying the root out using a sharp instrument that can be forced between the root and the bone surrounding it.  This technique is called “luxation“.  In the case of multiple rooted teeth, the roots are first separated so they can be removed individually.  Unfortunately, not all roots or root fragments may be removed in this fashion. This means that the dentist must make an incision into the gums around the tooth and raise a flap of tissue exposing the tooth and its surrounding bone.

Surgical Extraction – a. Gum flap is raised and surrounding bone is removed. b. The roots of the molar are split with a drill  and removed. c. The flap is held  back in place with sutures

Sometimes, after the flap is raised, there is enough tooth exposed to grab and remove it as in a simple extraction.  Sometimes, the technique described above as luxation may successfully remove the tooth.  If luxation fails,  the dentist must take a handpiece (drill) and cut away some of the surrounding bone in order to gain a purchase on the tooth. After the tooth has been pried out of the artificially enlarged socket, the dentist then sutures (sews) the flap of tissue back in place so that healing can proceed normally.

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Dr. Eddy Loo
12/Feb/2011

Topics

  • Introduction
  • Reasons for Extraction
  • Types of Extraction
  • Simple Extraction
  • What can I Expect After an Extraction?
  • Instructions after tooth extraction

Tooth extraction

Introduction
Generally, dentists do everything within their power to preserve your natural teeth. However, in cases of advance caries or periodontitis, a tooth may have to be extracted. Teeth may also be removed for the purposes of orthodontics when teeth are straightened using braces. For example, your front teeth may be skew because there is not enough room for them in your mouth. An orthodontist may, therefore, suggest extraction of certain teeth to make space for teeth in your jaw.

Reasons for Extraction

The most most common reason for extraction is tooth damage due to breakage or decay. There are additional reasons for tooth extraction:

  • Severe tooth decay or infection.
  • Extra teeth which are blocking other teeth from coming in.
  • Severe gum disease which may affect the supporting tissues and bone structures of teeth.
  • In preparation for orthodontic treatment (braces)
  • Teeth in the fracture line
  • Fractured teeth
  • Insufficient space for wisdom teeth (impacted third molars).
  • Receiving radiation to the head and neck may require extraction of teeth in the field of radiation.
  • Deliberate, medically unnecessary, extraction as a particularly dreadful form of physical torture.

Types of Extraction

Extractions are often categorized as “simple” or “surgical”.
1.) Simple extractions are performed on teeth that are visible in the mouth, usually under local anaesthetic, and require only the use of instruments to elevate and/or grasp the visible portion of the tooth. Typically the tooth is lifted using an elevator, and using dental forceps, rocked back and forth until the Periodontal ligament has been sufficiently broken and the supporting alveolar bone has been adequately widened to make the tooth loose enough to remove. Typically, when teeth are removed with forceps, slow, steady pressure is applied with controlled force.
2.) Surgical extractions involve the removal of teeth that cannot be easily accessed, either because they have broken under the gum line or because they have not erupted fully. Surgical extractions almost always require an incision. In a surgical extraction the doctor may elevate the soft tissues covering the tooth and bone and may also remove some of the overlying and/or surrounding jawbone tissue with a drill or osteotome. Frequently, the tooth may be split into multiple pieces to facilitate its removal. Surgical extractions are usually performed under a general anaesthetic.

Simple Extraction

To extract a tooth, your dentist first administers a local anaesthetic in the area. Next, he firmly places extraction forceps over the crown of the tooth. He manually loosens the tooth, and then removes it. This is the most basic method of tooth extraction. Alternatively, he places an elevator between the tooth and the tooth socket, and carefully levers the tooth out.
However, sometimes it is impossible to remove a tooth using these methods, and then surgical intervention is required. Under local or general anaesthetic, the gum is cut over the relevant area, and the bone exposed. A section of bone is then removed to expose the root of the tooth, which is removed. Finally, the gum is stitched back together again.

What can I Expect After an Extraction?

It is critical to keep the area clean and prevent infection immediately following the removal of a tooth. Your dentist will ask you to bite down gently on a piece of dry, sterile gauze, which you must keep in place for up to 30 to 45 minutes to limit bleeding while clotting takes place. For the next 24 hours, you shouldn’t smoke, rinse your mouth vigorously, or clean the teeth next to the extraction site.

Sterile gauze to be placed at the extracted socket to stop bleeding

A certain amount of pain and discomfort is to be expected following an extraction. In some cases, your dentist will recommend a pain killer or prescribe one for you. It may help to apply an ice pack to the face for 15 minutes at a time. You may also want to drink through a straw, limit strenuous activity, and avoid hot liquids. The day after the extraction, your dentist may suggest that you begin gently rinsing your mouth with warm salt water (do not swallow the water). Under normal circumstances, discomfort should lessen within three days to two weeks. If you have prolonged or severe pain, swelling, bleeding or fever, call your dentist at once.

Instructions after tooth extraction

These are the instruction usually given to reduce complication such as excessive bleeding or infection after extraction:

  1. Please don’t spit or rinse after extraction for today.
  2. Make sure to bite gauze which ha s been placed over the extracted socket.
  3. Please bite the gauze for 30 minutes to allow bleeding ceased.
  4. Please not to change gauze too often.
  5. Take pain killer given if painful.
  6. Avoid taking food or drink which is too hot.
  7. If socket still bleeds; not to be too worry. You can rinse gently with some cold water.
  8. You can brush your teeth but gently and avoid the extraction site.
  9. On the following day, rinse with salt water.

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