OMFS 4 - Intraoperative Complications (Dr. Stephens) !!

- Detailed surgical plan

- Needed instrumentation

- Anesthesia

- Pain management and postop

What are four aspects of the perioperative plan?

- Light

- Soft tissue retraction and reflection

- Suction

What factors allow clear visualization and access to field?

Soft tissue injuries

These are causes of what?

- Lack of attention to mucosa

- Inadequate access

- Excessive force

- Rushing procedure

Soft tissue injuries

These are types of what?

- Flap tear

- Puncture

- Abrasion or burn

Flap tear

What is the most common soft tissue injury?

Flap tear

What can occur with inadequate sized flap with forcible retraction beyond the ability of the tissue to stretch?

Flap tear

These are prevention measures for which injury?

- Creating adequately sized flaps to prevent excess tension on the flap

- Using controlled amounts of retraction force on the flap

- Creating releasing incisions when indicated

Hard tissue

______ surgery should be stopped while the incision is lengthened or while a releasing incision is created to gain better access

True

T/F: Careful suturing of the tear results in adequate but somewhat delayed healing

Puncture wound

Which soft tissue injury?

- Instrument such as a straight elevator or a periosteal elevator may slip from the surgical field and puncture or tear adjacent soft tissue

Uncontrolled force

(Finger rests or support from the opposite hand if slippage is anticipated)

A puncture wound is a result of what?

Preventing infection and allow healing to occur, usually by secondary intention

(Hemorrhage should be controlled by direct pres- sure applied to the wound)

What is the treatment of a puncture wound?

- Lips

- Corner of mouth

- Flaps

Where do abrasion/burns commonly occur? (3)

Abrasion/burn

These can cause what?

- Rotating shank of the burr rubbing on soft tissue

- Metal retractor coming in contact with soft tissue

Be aware of the location of the shank of the burr in relation to the patient's cheeks and lips

How can a burn/abrasion be prevented?

4-7 days

(depending on the depth of damage; without scarring - Advise the patient to keep it covered with an antibiotic ointment)

How long do abrasion/burns take to typically heal?

Tooth extraction

These are what types of complications?

- Root fracture

- Root displacement

- Tooth lost in pharynx

Root fracture

What is the most common problem associated with extraction?

Fracture

These types of roots are likely to have what complication?

- Long, curved, divergent roots that lie in dense bone

- Use an open extraction technique and remove bone to decrease the amount of force necessary to remove the tooth

(& perform surgery in the manner described in previous lectures)

How can we prevent root fractures?

- Surgical (l.e. open) extraction

- Do not use strong apical force on a broken root

If there is a high probability of root fracture, what type of extraction should you do?

Forced/lost into maxillary sinus

What is the most common root displacement?

Root displacement

ID the complication:

- Size of root

- Infection (If the tooth was not infected, management is more straightforward than if the tooth has been acutely infected)

- Pre-op condition of sinus

What are the three assessments the surgeon must make

if a root is displaced into the max. sinus?

True - only a brief attempt at removing the root

T/F: If a small 2-3 mm root tip is displaced into maxillary sinus, there is no pre-existing infection of tooth or root and you are unsuccessful at removing the root, it is okay to leave it in place

Radiograph

Irrigate

Leave the tip in the sinus

Inform patient of the decision and give home-car instructions

If a 3mm root tip is displaced into the maxillary sinus after attempting to extract. You attempt to retrieve it for 25 mins with no success. The root was not originally infected. How should you proceed?

True

T/F: Small, noninfected root tip can be left in place because itis unlikely to cause any troublesome sequelae

Violent sneezing

Blowing the nose

Sucking on straws

Smoking

What are four sinus precau-tions/things to avoid?

- Figure-of-eight suture over the socket

- Sinus precautions

- Antibiotics

- Nasal spray (Afrin)

If an oroantral communication is present, what are 4 post-op indications?

Root apex will fibrose onto the sinus membrane with no subsequent problems

What is the suspected outcome of a small uninfected root tip left in the maxillary sinus after being displaced?

Refer to OMFS

(Removal of the root tip via a Caldwell-Luc or endoscopic approach)

If a patient has an infection root left in the maxillary sinus and has chronic sinusitis, what do you do?

Remove root tip/tooth

If there is a large root fragment or entire tooth is displaced into the maxillary sinus, what is the indicated procedure?

Tooth lost in pharynx

The following is management for what?

- Mouth facing the floor as much as possible

- Encourage to cough and spit the tooth out onto the floor

- Transported to an ED and chest and abdominal radiographs should be taken to determine the specific location of the tooth

- Transport to emergency department

- Chest/abdomical x rays taken

If a tooth/crown is lost in the oral pharynx, what do you do regardless of if there is aspiration?

True

T/F: A tooth may be swallowed or aspiratea. Violent episode of coughing or shortness of breath, the tooth may have been aspirated through the vocal cords into the trachea and from there into a main-stem bronchus

Oropharyngeal isolation

How can you prevent teeth lost into the pharynx?

- Pay attention

- Time out and count the teeth

- Be aware of mixed dentition

- Take note of different tooth numbering systems used

How can you prevent the extraction of the wrong tooth?

Replaced quickly into the tooth socket and splint

Important to inform the patient or the patient's parents or caregivers

How do you manage the extraction of the wrong tooth?

Use of a burr to remove bone or to divide a tooth for removal

Avoid getting too close to adjacent teeth

Avoiding application of instrumentation and force on a restoration of an adjacent tooth

Recognize the potential to fracture a large restoration

Warn the patient preoperatively

Use elevators judiciously

The assistant should warn the surgeon of pressure on adjacent teeth

How can you prevent injury to adjacent teeth?

Inadvertent fracture or dislodgment of a restoration or damage to a severely carious tooth during elevation

What is the most common injury to adjacent teeth?

Inform patient risks before procedure

What is the most important thing to do if a patient has an adjacent severely carious tooth or adjacent restoration?

As a result of uncontrolled forces:

- Buccolingual forces inadequately mobilize a tooth, excessive tractional forces

- Tooth is suddenly released from the socket

How can teeth in the opposite arch also be injured?

Luxation of adjacent teeth

The following are characteristics of what?

- Results from inappropriate use of the extraction instru-

ments

- Prevented by judicious use of force with elevators and for-

ceps

- Crowded and has overlapping adjacent teeth-mandibu-lar anteriors

Reposition the tooth into its appropriate position and stabilize

(Simply be repositioned in the tooth socket and left alone or if mobile stabilized with semirigid fixation)

If an adjacent tooth is significantly luxated or partially avulsed what is the goal?

Fracture of alveolar process

ID the complication:

Alveolar bone fracture

What can happen if you use excessive force with forceps and straight elevator is not used enough?

Processes to avoid fracture of alveolar process

What are the following suggestions for?

- Soft tissue flap should be elevated

- Controlled amounts of bone should be removed so that the tooth can be delivered

- Multirooted teeth should be sectioned

D) Palatal bone adjacent to maxillar molars

Which of the following is NOT a location that is common for alveolar process fracture?

A) Buccal cortical plate at maxillary canine

B) Buccal cortical plate over maxillary molars

C) Portions of the floor of the maxillary sinus associated with maxillary molars

D) Palatal bone adjacent to maxillary molars

E) Maxillary tuberosity

F) Labial bone over mandibular incisor

Maxilla

Fractures of the alveolar process will most likely occur in which dental arch?

True

T/F: These are all prevention measures for fractures of alveolar process

- Assess the proximity of the roots to the maxillary sinus

- Consider the thickness of the buccal cortical plate overlying the tooth to be extracted

- Prevent fracturing excessive portions of bone

- Bones of older or larger patients are likely to be less elastic

- Consider performing the extraction by the open surgical technique

- Sectioning of the tooth roots into two or three portions

- Do not replace

- Soft tissue repositioned as best possible over the remaining bone to prevent delayed healing

- Smooth sharp edges

If bone is completely removed from the tooth socket, what do you do?

True

T/F: You can help prevent an alveolar process fracture by supporting the alveolar bone with your fingers during the extraction.

- Separated from the tooth and is left attached to the overlying soft tissue

- Dissect the bone with its attached associated soft tissue

- Bone and the soft tissue flap are reapproximated and secured with sutures

During an extraction you fracture part of the alveolar process. But part of the bone remains attached to the periosteum. What should you do next?

Fracture of maxillary tuberosity

ID the complication:

Bleeding

Delayed Healing

Denture stability is likely to be compromised

Oroantral communication

What is the sequelae of the fracture of a maxillary tuberosity?

- Erupted maxillary third molar

- Second molar if it is the last tooth in the arch

Fracture of maxillary tuberosity most commonly results from extraction of which teeth?

Splint tooth, wait 6-8 weeks for bone to heal

(Section the crown of the tooth from the roots and allow the tuberosity and tooth root section to heal. After 6 to 8 weeks the surgeon can remove the tooth roots in the usual fashion)

If the maxillary tuberosity is very mobile but will not come out, what do you do?

True

T/F: After the fracture of the maxillary tuberosity, check for an oroantral communication and provide the necessary treatment

True

T/F: Mandible fractures are rare and almost exclusively occur with surgical extraction of impacted 3rd molars

Mandible fracture

All of the following are characteristics of what type of frac-ture?

- Rare complication

- Almost exclusively with the surgical removal of impacted mandibular third molars

- Result of the application of a force exceeding that needed to remove a tooth

- Forceful use of dental elevators

- Deeply impacted

- Severely atrophic mandible

- Referto OMFS

CN V

(Branches are the mental, lingual, buccal, and nasopalatine nerves)

Branches of what cranial nerve...

- Provide innervation to the mucosa and skin, adjacent neural structures

- Most likely to be injured during extraction

- Nasopalatine nerves

- Buccal nerve

What nerves are frequently sectioned during the creation of flaps?

- Area of sensory innervation of these two nerves is relatively small, and reinnervation of the affected area usually occurs rapidly

- Can be surgically sectioned without long-lasting sequelae

Flaps

Nasopalatine and buccal nerves are frequently sectioned during creation of what?

Mental nerve

You are extracting mandibular premolar roots or impacted mandibular premolars. After the procedure the patient calls complaining of paresthesia of the lip and chin. What nerve did you injure?

Mandibular premolars

What teeth are near the mental nerve that you should be careful of when doing extractions or surgery?

- Lip

- Chin

(Normal sensation usually returns in a few days to a few weeks)

When the mental nerve is injured, where do patients have paresthesia/anesthesia?

Permanent state of anesthesia

A sectioned or torn mental nerve along its course could result in what?

True

T/F: It is imperative that the surgeon be aware of the potential morbidity from injury to the mental nerve

Vertical releasing incision

What type of incision must be placed far enough anteriorly to avoid severing any portion of the mental nerve?

Lingual nerve

What nerve?

Anatomically located directly against the lingual aspect of the mandible in the retromolar pad region

Occasionally the path takes it into the retromolar pad area itself

Rarely regenerates if it is severely traumatized

Buccal aspect of mandible

How do you avoid lingual nerve injuries when taking out third molars or bony areas in the posterior molar region?

True

T/F: Dissecting a flap involving the retromolar pad, care must be taken to avoid excessive dissection or stretching of

the tissues on the lingual aspect

IAN

What nerve?

- May be traumatized along the course of its intrabony canal

- Most common place of injury is the area of the mandibular third molar

- May bruise, crush, or sharply injure the nerve in its canal

Routinely to inform patients preoperatively that it is a possibility

Refer to OMFS ASAP

(If nerve repair is indicated, the sooner the repair is made, the better the chances of full recovery of nerve function)

What should you do if the Lingual or inferior alveolar nerves are damaged?

Mandibular 3rd molar

Where is the most common place of injury of the IAN?

Mandible

TMJ injury can occur during extraction procedure in the

__________ due to application of substantial force or jaw being inadequately supported

Avoid excessive force

Bite block on the contralateral side

Assistant holds pressure to jaw

What are ways to avoid TMJ in-juries?

600 to 800 mg every 4 hours for several days

If TMJ injury occurs, what is the ibuprofen regimen?

500-1000 mg of acetaminophen

If TMJ injury occurs, and a patient cannot tolerate NSAIDS, what is the analgesic regimen?

A) HEAT

All of the following is management for patients that experience a TMJ injury from an extraction except:

A) Cold Compress

B) Resting the jaw

C) Soft diet

D) 600 to 800 mg of ibuprofen every 4 hours for several days.

E) Patients who cannot tolerate NSAIDs may take 500 to 1000 mg of acetaminophen

Oroantral communication

What may occur if...

- Maxillary sinus is greatly pneumatized

- Little or no bone exists between the roots of the teeth and the maxillary sinus

- Roots of the tooth are widely divergent

True (Oroantral communication)

T/F: Common for a portion of the bony floor of the sinus to be removed with the tooth or a communication to be created even if no bone comes out with the tooth

- Postoperative maxillary sinusitis

- Formation of a chronic oroantral fistula

What are the post-op seque-lae of an oroantral communcation?

Oroantral communication

Patient presents with the following radiograph and you need to do an extraction. What are you mostly concerned about happening?

Prevention

What is the best management of oroantral communication?

Avoid a closed extraction and perform a surgical removal with sectioning of tooth roots

Patient presents for an extrac-tion. The sinus floor is way too close to the roots of the tooth that needs to be extracted and the roots are widely divergent. What should you do?

Excessive force

If oroantral communication is a concern, __________ should be avoided in the removal of such maxillary molars

Examine tooth for adherent bone

Nose-blowing test (MAYBE)

Direct observation of socket

Approximate size

How can you diagnose an oroantral communication?

Nose-blowing test

*poses risk of creating one!!!!!

What is NOT an appropriate diagnostic test to see it a patient has a oroantral communi-cation?

2mm

It you suspect an oroantral communication, and no bone comes out with the tooth, the communication is likely to be _________mm or less in diameter...

- No additional surgical tx necessary

- Ensure the formation of a high-quality blood clot in the socket

- Sinus precautions to prevent dislodgment of the blood clot

True

(Bone of the sinus may possibly have been removed without perforation of the sinus mucosa)

T/F: If you have an oroantral communication, you must not probe through the socket

- Gelatin sponge (GelFoam)

- Protect clot with a figure-of-eight suture

If there is a moderate oroantral communication (2-6 mm), What do you do when closing the socket?

- Antibiotics — usually amoxicillin, cephalexin, or clindamycin-should be prescribed for 5 days

- Decongestant nasal spray should be prescribed to shrink the nasal mucosa to maintain patency of the ostium

What medications reduce risk of maxillary sinusitis when you have a moderate oroantral communication?

OMFS performs flap surgery ASAP

If there is a large oroantral communication (>7 mm),

What do you do?

Buccal flap

What type of flap mobilizes buccal soft tissue/ fat pad to cover the opening and provide for a primary closure?

OMFS/ ENT

Patients with any communication with history of chronic sinusitis should be referred to _______

Nose

Patients with persistent OA fistula complain of leakage of fluids from the mouth into the ________

Loss of suction and retention of the denture compromised

What happens to patient's with dentures who have an oroantral communication?

F) All of the above

Which of the following is a factor that influences the difficulty of stopping post-operative bleeding?

A) Tissues of the mouth and jaws are highly vascular

B) Extraction of a tooth leaves an open wound, with soft tissue and bone remaining open, which allows additional oozing and bleeding

C) Almost impossible to apply dressing material with enough pressure and sealing to prevent additional bleeding during surgery

D) Patients occasionally dislodge blood clots with tongue, or the tongue may cause secondary bleeding by creating small negative pressures

E) Salivary enzymes may lyse the blood clot before it has organized and before the in-growth of granulation tissue

F) All of the above

Prevention

What is the best management of post-op bleeding?