| Surgical-Dentistry.Info |
Teeth are removed for a number of reasons.
Typically, the tooth is extensively decayed or
fractured and is causing chronic infection and
discomfort.
Sometimes, the tooth has to be removed surgically.
Surgical removal is needed when simple extraction is
not possible because of the condition of the tooth.
The following list of warnings regarding tooth extraction is
neither exhaustive nor is it predictive. The most pertinent
warnings have been included here.
Common Surgical Consequences:
Pain. As it is a surgical procedure, there will be soreness
after the tooth removal. This can last for several days.
Painkillers such as Ibuprofen, Paracetamol, Solpadeine or
Nurofen Plus are very effective. Obviously, the painkiller
you use is dependent on your medical history & the ease
with which the tooth was removed.
Swelling. There will be swelling afterwards. This can last
up to a week. Use of an ice-pack or a bag of frozen peas
pressed against the cheek adjacent to the tooth removed
will help to lessen the swelling. Avoidance in the first few
hours post-op, of alcohol, exercise or hot foods / drinks
will decrease the degree of swelling as well.
Bruising. Some people are prone to bruise. Older people,
people on aspirin or steroids will also bruise that much
more easily. The bruising can look quite florid; this will
eventually resolve but can take several weeks (in the
worst cases).
Stitches. The extraction site will often be closed with
stitches. These dissolve and ‘fall out’ within 10 – 14 days.
Limitation of Mouth Opening (Trismus). Often the chewing
muscles and the jaw joints are sore after the procedure so
that mouth opening can be limited for the next few days. If
you are unlucky enough to develop an infection afterwards
in the socket, this can make the limited mouth opening
worse and last for longer (up to a week).
Post-op Infection. You may develop an infection in the
socket after the operation. This tends to occur 2 – 4 days
later and is characterised by a deep-seated throbbing
pain, bad breath and an unpleasant taste in the mouth.
This infection is more likely to occur if you are a smoker,
are on the Contraceptive Pill, on drugs such as steroids
and if bone has to be removed to facilitate tooth extraction.
If antibiotics are given, they are likely to react with alcohol
and/or the Contraceptive Pill (that is, the ‘Pill’ will not be
providing protection).
Adjacent Teeth. The surrounding teeth may be sore after
the extraction; they may even be slightly wobbly but the
teeth should settle down with time. It is possible that the
fillings or crowns of the surrounding teeth may come out,
fracture or become loose. If this is the case, you will need
to go back to your dentist to have these sorted out. Every
effort will be made to make sure this doesn’t happen. In
very rare instances, the surrounding teeth may actually
come out as well as the intended tooth.
Surgical Removal. To ease the removal of teeth, it is
sometimes necessary to cut the gum and/or remove bone
from around the tooth. If this is the case, you can expect
the extraction site to be more sore afterwards, the
swelling to be greater and more likely to become infected.
Hence, stronger painkillers are needed; use of icepacks
necessary and antibiotics will probably be prescribed. The
bone grows back to a greater extent. Care though will be
taken not to be ‘wasteful’ in bone removal as this effects
afterwards the provision of dentures, bridges and implants.
Less Common Surgical Consequences:
Numbness / Tingling / 'Burning' of the Lip, Chin and/or
Tongue. The nerves that supply feeling to the tongue,
lower lip and the chin run close to the root-ends of the
lower molar teeth and exit onto the gum close to the roots
of the premolars / bicuspids. There is a risk that when
back lower teeth (wisdom teeth especially) are removed,
these nerves can be crushed, bruised or stretched
resulting in numbness (at the worse end of the scale) to
altered sensation (at the other end of the scale) in the
region of the lower lip, chin and/or tongue.
This nerve bruising tends to be temporary (rarely is it
permanent) but ‘temporary’ can stretch from several days
to several months. It is hard to predict who will get nerve
bruising and if it will be temporary / permanent and if
temporary, how long for.
Left Behind Tooth Tips. In rare instances, the very ends of
the teeth may be left behind.
In the lower jaw, this is done because in trying to remove
these root tips, the nerve supplying feeling to the lip, chin &
tongue may be damaged. If they are left behind, there is
not likely to be any problems associated with this.
In the upper jaw, these root tips may stay where they are
in the socket or may be pushed into the sinus or into a
local blood vessel network (pterygoid plexus). If these
tips are left behind in the socket, there is not likely to be
any problems associated with this. However, if the root
tips have gone out of the socket into the local anatomy,
they will need to be recovered.
Bony Flakes. Occasionally, bony flakes (sequestra) from
the sockets of the extracted teeth can work their way
loose and through the gums. These can be quite sore.
They often work their way loose without any problems but
may need to be teased out or even smoothed. If a
number of teeth are removed at one go, the resulting gums
may feel a bit rough. In many cases, the gums become
less rough with time however, it may be necessary to
smooth the underlying bone for this to happen.
Failure of Anæsthesia. In rare cases, the tooth can be
difficult to ‘numb up’. This can be due to a number of
reasons. The more common ones include inflammation ±
infection associated with the tooth, anatomical differences
& apprehension. If the tooth fails to ‘numb up’ then its
removal will be rescheduled with antibiotic cover or
perhaps done under sedation or even a GA.
Bleeding into Cheeks. Swelling that does not resolve
within a few days may be due to bleeding into the cheek.
The cheek swelling will feel quite firm. Coupled with this,
there may be limitation to mouth opening and bruising.
Both the swelling, bruising and mouth opening will resolve
with time.
Mouth-Sinus Communications. Upper molar and premolar
teeth often have their roots in close proximity to the sinus.
In removing these teeth, there is a chance that a ‘hole’ can
be made between the mouth & the sinus (this is
sometimes not evident at the time of operation but may
develop several weeks afterwards). If this ’hole’ persists
or is left un-repaired, every time you drink, fluid can come
out of the nose and you may develop a marked sinusitis.
This ‘hole’ if small enough, can spontaneously close. It can
be assisted in this by ‘cover plates’ that prevents food &
fluids going into the sinus allowing the hole to close
naturally. However, ‘holes’ above a certain size need to be
surgically closed.
Fractured Tuberosity. The upper molars can, from time to
time, be fused with the bone around them so that in
removing the molar tooth, the bony socket within which the
tooth sits (tuberosity) comes with it. This can make the
mouth-sinus communication larger (see above) and
sometimes, the adjacent teeth and their bony sockets
comes attached with the extracted tooth.
Closure of the ‘hole’ is followed with antibiotics, painkillers
& decongestants. Nose-blowing is forbidden for a week
afterwards (at least).
Rare Surgical Consequences:
Prolonged Period of Disability.
Prolonged Pain.
Prolonged Limitation of Mouth Opening (Trismus). This
can be due to medial pterygoid contracture / spasm.
This spasm may be the result of injury of the medial
pterygoid muscle caused by a needle (repeated injections
during Inferior Alveolar Nerve block) or by trauma of the
surgical field especially when difficult lengthy surgical
procedures are performed. Other causative factors are
inflammation of the post-extraction wound, hæmatoma and
post-operative œdema.
The management of trismus depends on the cause. Most
cases do not require any particular therapy. When acute
inflammation or a hæmatoma is the cause of trismus, hot
mouth rinses are recommended initially and then broad-
spectrum antibiotics are administered.
Other supplementary therapeutic measures include:
Prolonged Bleeding from the Extraction Site. Incidence:
0.6 - 5% with higher incidence in older age groups.
Most patients with a bleeding disorders are diagnosed
early in life and their medical history is available to the oral
surgeon. Nevertheless, cases are still occasionally
diagnosed for the first time following dental extraction.
The majority of patients who bleed after extractions do not
have any underlying hæmatological disorder and they
generally have had extractions previously without
complication, suggesting a purely local factor in the
hæmorrhage.
Pre-operative screening of patients with no relevant history
for blood-clotting disorders is not an effective means of
identifying patients who may bleed postoperatively.
There exists a small group of patients who bleed after
dental extractions on each occasion but do not bleed after
extra-oral trauma and do not show any abnormality on
hæmatologic testing. It has been suggested that oral
fibrinolysis, probably of salivary origin, may be responsible
for destruction / lysis of the blood clots and consequent
hæmorrhage in such patients. Fibrin-stabilising factors,
such as ε-aminocaproic acid and transexamic acid may
be helpful in these cases.
Prolonged Swelling. Discomfort, swelling and œdema are
normally considered inevitable consequences of wisdom
tooth removal but as part of general improvement in
patient care, all reasonable steps would have been taken
to minimise them.
Excessive operative time, difficulty of extraction (such as
bone removal) and flap retraction increase the swelling
associated with surgery.
Periodontal Complications. Removal of wisdom teeth is
often carried out to preserve gum / periodontal health or,
in some situations, to treat existing gum disease-
pyorrhoea / periodontitis. With a partially impacted lower
wisdom tooth, there is already a periodontal pocket on the
mesial aspect of the wisdom tooth as well as a bony /
osseous defect in the bone on the distal root of the second
molar. This situation can, under certain circumstances,
progress to rapid periodontal destruction.
Post-operative measurements show lower bone levels and
deeper pocket depth than desirable.
Some studies have grouped patients into treatment groups
according to age. It is suggested that patients < 19 years,
between 20 - 35 years, > 35 years may have different
periodontal healing potentials following lower third molar
removal.
In most young patients (< 19 years), bone height after
wisdom tooth removal appears similar to the pre-operative
level. In fact, some studies even show a gain in bone level
following surgery. If the bone level distal to the second
molar is compromised before wisdom tooth removal, it
normally remains below the normal level post-operatively.
The greatest bone defects occur in older patients (> 35
years), in whom the wisdom teeth have already resorbed
part of the second molar. Periodontal pocket depth
appears to be the same post-operatively as pre-
operatively and in older patients, pocket depth may even
increase following removal of the wisdom tooth.
In younger patients, however, there appears to be no
adverse effect on pocket depth. In younger patients,
reduction in pocket depth can occur for up to 4 years
following surgery though this benefit may not occur in older
patients.
Systemic Medical / Surgical complications / Death during
Operative / Post-Operative Period.
Complications associated with Local Anæsthetic, Sedation
or General Anæsthetic.
Development of Excessive Blood Clot / Bruising.
Development of excessive blood clot (hæmatoma) in
chewing muscles, tissue spaces etc may manifest itself on
the face and slump into the submandibular region and
then down the neck onto the chest.
Also, effects of blood clots being converted into scar
tissue – prolonged trismus. Hæmatoma formation outwith
the socket can occur and may require drainage.
Unscheduled Secondary Surgical Procedure.
Ludwig’s Angina.
Acute / Chronic / Local / Systemic Infection including
Development of Osteomyelitis.
Persistence of / Development of New Pathology (eg.
recurrent or residual cyst or tumour)
Post-Extraction Granuloma. This complication occurs 4 –
5 days after the extraction of the tooth and is the result of
the presence of a foreign body in the tooth socket e.g.
amalgam remnants (from the tooth filling), bone chips,
small tooth fragments, calculus etc. Foreign bodies irritate
the area, so that post-extraction healing ceases and there
is suppuration of the wound.
This complication is treated with debridement of the socket
and removal of any / every causative agent.
Lingual Plate Fracture. This is seen with:
The plate fragment is often adherent to the wisdom tooth.
Dependent on its size, it can be dissected out. The socket
will need to be ‘tidied up’ (the archaic term “wound toilet”
is used). It is very likely that the Lingual Nerve has been
traumatised whilst this is being done. This will result in
nerve damage that ranges from numbness of the tongue to
'pins and needles' or 'burning' of that side of the tongue
as the extraction to loss of taste.
Introduction / Displacement of Tooth, Tooth Fragments or
other Foreign Body / Bodies into Adjacent Anatomical
Zones.
Jaw Dislocation. It can be extremely uncomfortable having
a lower molar tooth extracted, not because of pain at the
surgical site but because of traction on the
temporomandibular joints (TMJ) / jaw joints, consequent to
the oral surgeon pushing down on the tooth with the
extraction forceps. It is important that the surgeon fully
supports the lower jawe during extractions in order to
relieve stresses on the TMJ.
Where extractions are performed under General
Anæsthetic, it is all too easy to forget the TMJ. On
completion of treatment, immediately prior to removing the
throat pack, the oral surgeon should manipulate the lower
jaw into centric occlusion to ensure that it is not dislocated
(i.e. the lower jaw has gone back into its correct position).
If it is not, then the dislocation should be reduced before
the anæsthetic is reversed and the patient woken up.
Removal of wisdom teeth may cause / exacerbate a pre-
existing TMJ problem. This complication is best prevented
by allowing the patient to bite on a prop and rest every
few minutes if the procedure is prolonged. If TMJ
problems do occur following wisdom teeth removal or
other oral surgical procedures, they must be treated in the
normal way utilising predominantly non-surgical modalities,
such as rest, heat, muscle relaxants and possibly, bite-
raising appliances / occlusal splints.
Exposure of an Inappropriate / Unplanned Operative Site
(eg. incorrect side)
Extraction of the Wrong Tooth. Extraction of the wrong
tooth is an avoidable error which can easily be prevented
by ensuring that proper identification of the patient and
tooth to be extracted, is made.
Teeth commonly extracted in error are upper canines
instead of upper first premolars, lower permanent
premolars simultaneously with lower deciduous molars and
upper second molars instead of upper third molars. The
latter is particularly liable to occur if the upper third molar
is partially erupted and difficult to visualise.
Being aware of the possibility of these errors and
“counting out” the tooth to be extracted will go some way
to minimising their occurrence.
A common source of confusion is the correct identification
of one of 2 molar teeth when the other molar is missing or
absent. Although a naming convention exists for just this
situation, longhand notation such as “the first standing
lower right molar” instead of the lower right 7 may help
avoid confusion where the third molar is erupted and the
first molar is absent.
A similar situation occurs when only one of 2 unerupted
and adjacent teeth are to be extracted. Again, this is
commonly requested as part of an orthodontic treatment
plan and as such should be avoided at all costs.
If the wrong tooth is extracted, the oral surgeon should
proceed with removing the correct tooth unless the
extractions are for orthodontic purpose when it may be
better to seek the advice of the patients’ orthodontist first.
The tooth extracted in error, particularly if it is otherwise
healthy, should be immediately replaced in its socket. If
mobile, it should be held in place with a custom made
vacuum-formed splint for approximately 4 weeks. It is
likely that it will subsequently require to be root-filled and if
there is any doubt about its prognosis, the advice of a
consultant restorative dentist should be sought.
Fractured Upper / Lower Jaw secondary to Tooth
Removal. Incidence: 2 - 4% (including alveolar and lingual
plate fractures, so the incidence of actual fractures of the
upper and lower jaws is likely to be much less).
This is probably the most feared of all complications
following Minor Oral Surgery and like the majority of them
is largely preventable. It is a recognised complication of
lower wisdom tooth removal and should be listed as such
on a routine consent form.
Fracture of the mandible / lower jaw is a very unpleasant
but fortunately rare complication that is associated almost
exclusively with the extraction of impacted lower wisdom
teeth
There are a number of predisposing conditions, such as:
When a fracture occurs during the extraction, the tooth
must be removed before any other procedure is carried
out, in order to avoid infection along the line of the fracture.
The fracture must be repaired if necessary - if the
operator is unable to do this, they must arrange an
immediate referral. Afterwards, depending on the case,
stabilisation by way of inter-maxillary fixation or rigid
internal fixation of the jaw segments is applied for 4 – 6
weeks and broad-spectrum antibiotics are administered.
Patients should be advised to consume a soft diet for
several weeks and to return immediately if they become
aware of any abnormalities in the jaw.
Fracture / Failure of Instrument with Retention of
Instrument Fragment within Bone / Soft Tissue. Any
broken instrument should be removed at the time of the
operation. If not retrievable, the patient should be told and
this recorded in the notes.
Suture needles, hypodermic needles and surgical burrs are
the items that most frequently fracture / fail in use. Suture
needles are probably the commonest items to be broken
during minor oral surgery.
As a general rule, all fragments of broken instruments
should be removed immediately before they have time to
migrate deeper into the tissues.
If the fragment cannot be found, radiographs in 2 planes at
90° should be taken of the operative area to locate it. At
this point, a decision will need to be taken as to whether to
remove the fragment or leave it in situ depending on its
size and site.
Small fragments lying sub-periostealy can be safely left as
they are unlikely to migrate and cause problems. If the
decision is taken to remove the fragment, the operative
approach will depend on where it is located and a
thorough knowledge of the local anatomy is essential if
further complications are to be avoided. It should be
remembered that small fine foreign bodies can be
extremely difficult to locate and that blind exploration of
tissue spaces is wont to displace them deeper. The use
of image intensification can be very helpful in this situation.
Breakage of an instrument in the tissues is the result of
excessive force during the removal of the tooth and usually
involves the end of the blade of various elevators or bur.
Breakage may be the result of repeated use of the
instrument altering its metallic composition (mainly of the
bur). In these cases, after precise radiographic
localisation, the broken piece(s) are removed surgically at
the same time as extraction of the tooth or root.
Soft Tissue Damage
Typically, the tooth is extensively decayed or
fractured and is causing chronic infection and
discomfort.
Sometimes, the tooth has to be removed surgically.
Surgical removal is needed when simple extraction is
not possible because of the condition of the tooth.
The following list of warnings regarding tooth extraction is
neither exhaustive nor is it predictive. The most pertinent
warnings have been included here.
Common Surgical Consequences:
Pain. As it is a surgical procedure, there will be soreness
after the tooth removal. This can last for several days.
Painkillers such as Ibuprofen, Paracetamol, Solpadeine or
Nurofen Plus are very effective. Obviously, the painkiller
you use is dependent on your medical history & the ease
with which the tooth was removed.
Swelling. There will be swelling afterwards. This can last
up to a week. Use of an ice-pack or a bag of frozen peas
pressed against the cheek adjacent to the tooth removed
will help to lessen the swelling. Avoidance in the first few
hours post-op, of alcohol, exercise or hot foods / drinks
will decrease the degree of swelling as well.
Bruising. Some people are prone to bruise. Older people,
people on aspirin or steroids will also bruise that much
more easily. The bruising can look quite florid; this will
eventually resolve but can take several weeks (in the
worst cases).
Stitches. The extraction site will often be closed with
stitches. These dissolve and ‘fall out’ within 10 – 14 days.
Limitation of Mouth Opening (Trismus). Often the chewing
muscles and the jaw joints are sore after the procedure so
that mouth opening can be limited for the next few days. If
you are unlucky enough to develop an infection afterwards
in the socket, this can make the limited mouth opening
worse and last for longer (up to a week).
Post-op Infection. You may develop an infection in the
socket after the operation. This tends to occur 2 – 4 days
later and is characterised by a deep-seated throbbing
pain, bad breath and an unpleasant taste in the mouth.
This infection is more likely to occur if you are a smoker,
are on the Contraceptive Pill, on drugs such as steroids
and if bone has to be removed to facilitate tooth extraction.
If antibiotics are given, they are likely to react with alcohol
and/or the Contraceptive Pill (that is, the ‘Pill’ will not be
providing protection).
Adjacent Teeth. The surrounding teeth may be sore after
the extraction; they may even be slightly wobbly but the
teeth should settle down with time. It is possible that the
fillings or crowns of the surrounding teeth may come out,
fracture or become loose. If this is the case, you will need
to go back to your dentist to have these sorted out. Every
effort will be made to make sure this doesn’t happen. In
very rare instances, the surrounding teeth may actually
come out as well as the intended tooth.
Surgical Removal. To ease the removal of teeth, it is
sometimes necessary to cut the gum and/or remove bone
from around the tooth. If this is the case, you can expect
the extraction site to be more sore afterwards, the
swelling to be greater and more likely to become infected.
Hence, stronger painkillers are needed; use of icepacks
necessary and antibiotics will probably be prescribed. The
bone grows back to a greater extent. Care though will be
taken not to be ‘wasteful’ in bone removal as this effects
afterwards the provision of dentures, bridges and implants.
Less Common Surgical Consequences:
Numbness / Tingling / 'Burning' of the Lip, Chin and/or
Tongue. The nerves that supply feeling to the tongue,
lower lip and the chin run close to the root-ends of the
lower molar teeth and exit onto the gum close to the roots
of the premolars / bicuspids. There is a risk that when
back lower teeth (wisdom teeth especially) are removed,
these nerves can be crushed, bruised or stretched
resulting in numbness (at the worse end of the scale) to
altered sensation (at the other end of the scale) in the
region of the lower lip, chin and/or tongue.
This nerve bruising tends to be temporary (rarely is it
permanent) but ‘temporary’ can stretch from several days
to several months. It is hard to predict who will get nerve
bruising and if it will be temporary / permanent and if
temporary, how long for.
Left Behind Tooth Tips. In rare instances, the very ends of
the teeth may be left behind.
In the lower jaw, this is done because in trying to remove
these root tips, the nerve supplying feeling to the lip, chin &
tongue may be damaged. If they are left behind, there is
not likely to be any problems associated with this.
In the upper jaw, these root tips may stay where they are
in the socket or may be pushed into the sinus or into a
local blood vessel network (pterygoid plexus). If these
tips are left behind in the socket, there is not likely to be
any problems associated with this. However, if the root
tips have gone out of the socket into the local anatomy,
they will need to be recovered.
Bony Flakes. Occasionally, bony flakes (sequestra) from
the sockets of the extracted teeth can work their way
loose and through the gums. These can be quite sore.
They often work their way loose without any problems but
may need to be teased out or even smoothed. If a
number of teeth are removed at one go, the resulting gums
may feel a bit rough. In many cases, the gums become
less rough with time however, it may be necessary to
smooth the underlying bone for this to happen.
Failure of Anæsthesia. In rare cases, the tooth can be
difficult to ‘numb up’. This can be due to a number of
reasons. The more common ones include inflammation ±
infection associated with the tooth, anatomical differences
& apprehension. If the tooth fails to ‘numb up’ then its
removal will be rescheduled with antibiotic cover or
perhaps done under sedation or even a GA.
Bleeding into Cheeks. Swelling that does not resolve
within a few days may be due to bleeding into the cheek.
The cheek swelling will feel quite firm. Coupled with this,
there may be limitation to mouth opening and bruising.
Both the swelling, bruising and mouth opening will resolve
with time.
Mouth-Sinus Communications. Upper molar and premolar
teeth often have their roots in close proximity to the sinus.
In removing these teeth, there is a chance that a ‘hole’ can
be made between the mouth & the sinus (this is
sometimes not evident at the time of operation but may
develop several weeks afterwards). If this ’hole’ persists
or is left un-repaired, every time you drink, fluid can come
out of the nose and you may develop a marked sinusitis.
This ‘hole’ if small enough, can spontaneously close. It can
be assisted in this by ‘cover plates’ that prevents food &
fluids going into the sinus allowing the hole to close
naturally. However, ‘holes’ above a certain size need to be
surgically closed.
Fractured Tuberosity. The upper molars can, from time to
time, be fused with the bone around them so that in
removing the molar tooth, the bony socket within which the
tooth sits (tuberosity) comes with it. This can make the
mouth-sinus communication larger (see above) and
sometimes, the adjacent teeth and their bony sockets
comes attached with the extracted tooth.
Closure of the ‘hole’ is followed with antibiotics, painkillers
& decongestants. Nose-blowing is forbidden for a week
afterwards (at least).
Rare Surgical Consequences:
Prolonged Period of Disability.
Prolonged Pain.
Prolonged Limitation of Mouth Opening (Trismus). This
can be due to medial pterygoid contracture / spasm.
This spasm may be the result of injury of the medial
pterygoid muscle caused by a needle (repeated injections
during Inferior Alveolar Nerve block) or by trauma of the
surgical field especially when difficult lengthy surgical
procedures are performed. Other causative factors are
inflammation of the post-extraction wound, hæmatoma and
post-operative œdema.
The management of trismus depends on the cause. Most
cases do not require any particular therapy. When acute
inflammation or a hæmatoma is the cause of trismus, hot
mouth rinses are recommended initially and then broad-
spectrum antibiotics are administered.
Other supplementary therapeutic measures include:
- Heat therapy, i.e., hot compresses are placed extra-
orally for approximately 20 min every hour until
symptoms subside. - Gentle massage of the TMJ area.
- Administration of painkillers, anti-inflammatory and
muscle relaxant (such as sedatives) medication. - Physiotherapy lasting 3 – 5 min every 3 – 4 hours,
which includes movements of opening and closing the
mouth, as well as lateral movements, aimed at
increasing the extent of mouth opening. - Administration of sedatives for management of stress
which worsens while trismus persists, leading to an
increase of muscle spasm in the area
Prolonged Bleeding from the Extraction Site. Incidence:
0.6 - 5% with higher incidence in older age groups.
Most patients with a bleeding disorders are diagnosed
early in life and their medical history is available to the oral
surgeon. Nevertheless, cases are still occasionally
diagnosed for the first time following dental extraction.
The majority of patients who bleed after extractions do not
have any underlying hæmatological disorder and they
generally have had extractions previously without
complication, suggesting a purely local factor in the
hæmorrhage.
Pre-operative screening of patients with no relevant history
for blood-clotting disorders is not an effective means of
identifying patients who may bleed postoperatively.
There exists a small group of patients who bleed after
dental extractions on each occasion but do not bleed after
extra-oral trauma and do not show any abnormality on
hæmatologic testing. It has been suggested that oral
fibrinolysis, probably of salivary origin, may be responsible
for destruction / lysis of the blood clots and consequent
hæmorrhage in such patients. Fibrin-stabilising factors,
such as ε-aminocaproic acid and transexamic acid may
be helpful in these cases.
Prolonged Swelling. Discomfort, swelling and œdema are
normally considered inevitable consequences of wisdom
tooth removal but as part of general improvement in
patient care, all reasonable steps would have been taken
to minimise them.
Excessive operative time, difficulty of extraction (such as
bone removal) and flap retraction increase the swelling
associated with surgery.
Periodontal Complications. Removal of wisdom teeth is
often carried out to preserve gum / periodontal health or,
in some situations, to treat existing gum disease-
pyorrhoea / periodontitis. With a partially impacted lower
wisdom tooth, there is already a periodontal pocket on the
mesial aspect of the wisdom tooth as well as a bony /
osseous defect in the bone on the distal root of the second
molar. This situation can, under certain circumstances,
progress to rapid periodontal destruction.
Post-operative measurements show lower bone levels and
deeper pocket depth than desirable.
Some studies have grouped patients into treatment groups
according to age. It is suggested that patients < 19 years,
between 20 - 35 years, > 35 years may have different
periodontal healing potentials following lower third molar
removal.
In most young patients (< 19 years), bone height after
wisdom tooth removal appears similar to the pre-operative
level. In fact, some studies even show a gain in bone level
following surgery. If the bone level distal to the second
molar is compromised before wisdom tooth removal, it
normally remains below the normal level post-operatively.
The greatest bone defects occur in older patients (> 35
years), in whom the wisdom teeth have already resorbed
part of the second molar. Periodontal pocket depth
appears to be the same post-operatively as pre-
operatively and in older patients, pocket depth may even
increase following removal of the wisdom tooth.
In younger patients, however, there appears to be no
adverse effect on pocket depth. In younger patients,
reduction in pocket depth can occur for up to 4 years
following surgery though this benefit may not occur in older
patients.
Systemic Medical / Surgical complications / Death during
Operative / Post-Operative Period.
Complications associated with Local Anæsthetic, Sedation
or General Anæsthetic.
Development of Excessive Blood Clot / Bruising.
Development of excessive blood clot (hæmatoma) in
chewing muscles, tissue spaces etc may manifest itself on
the face and slump into the submandibular region and
then down the neck onto the chest.
Also, effects of blood clots being converted into scar
tissue – prolonged trismus. Hæmatoma formation outwith
the socket can occur and may require drainage.
Unscheduled Secondary Surgical Procedure.
Ludwig’s Angina.
Acute / Chronic / Local / Systemic Infection including
Development of Osteomyelitis.
Persistence of / Development of New Pathology (eg.
recurrent or residual cyst or tumour)
Post-Extraction Granuloma. This complication occurs 4 –
5 days after the extraction of the tooth and is the result of
the presence of a foreign body in the tooth socket e.g.
amalgam remnants (from the tooth filling), bone chips,
small tooth fragments, calculus etc. Foreign bodies irritate
the area, so that post-extraction healing ceases and there
is suppuration of the wound.
This complication is treated with debridement of the socket
and removal of any / every causative agent.
Lingual Plate Fracture. This is seen with:
- horizontally / mesially impacted lower wisdom teeth
that have been partially erupted for awhile together
with - low-grade infection associated with them (such as
pericoronitis or periodontitis) - African origin (denser bone)
- the more mature patient (sclerotic bone)
- the use of chisels / osteotomes, utilised in the
decoronating of lower wisdom teeth (Lingual Split
Technique used to ‘saucerise the socket’).
The plate fragment is often adherent to the wisdom tooth.
Dependent on its size, it can be dissected out. The socket
will need to be ‘tidied up’ (the archaic term “wound toilet”
is used). It is very likely that the Lingual Nerve has been
traumatised whilst this is being done. This will result in
nerve damage that ranges from numbness of the tongue to
'pins and needles' or 'burning' of that side of the tongue
as the extraction to loss of taste.
Introduction / Displacement of Tooth, Tooth Fragments or
other Foreign Body / Bodies into Adjacent Anatomical
Zones.
- Maxillary sinus
- Tissue spaces
- Inferior Dental Canal
- Aero-digestive tract
Jaw Dislocation. It can be extremely uncomfortable having
a lower molar tooth extracted, not because of pain at the
surgical site but because of traction on the
temporomandibular joints (TMJ) / jaw joints, consequent to
the oral surgeon pushing down on the tooth with the
extraction forceps. It is important that the surgeon fully
supports the lower jawe during extractions in order to
relieve stresses on the TMJ.
Where extractions are performed under General
Anæsthetic, it is all too easy to forget the TMJ. On
completion of treatment, immediately prior to removing the
throat pack, the oral surgeon should manipulate the lower
jaw into centric occlusion to ensure that it is not dislocated
(i.e. the lower jaw has gone back into its correct position).
If it is not, then the dislocation should be reduced before
the anæsthetic is reversed and the patient woken up.
Removal of wisdom teeth may cause / exacerbate a pre-
existing TMJ problem. This complication is best prevented
by allowing the patient to bite on a prop and rest every
few minutes if the procedure is prolonged. If TMJ
problems do occur following wisdom teeth removal or
other oral surgical procedures, they must be treated in the
normal way utilising predominantly non-surgical modalities,
such as rest, heat, muscle relaxants and possibly, bite-
raising appliances / occlusal splints.
Exposure of an Inappropriate / Unplanned Operative Site
(eg. incorrect side)
Extraction of the Wrong Tooth. Extraction of the wrong
tooth is an avoidable error which can easily be prevented
by ensuring that proper identification of the patient and
tooth to be extracted, is made.
Teeth commonly extracted in error are upper canines
instead of upper first premolars, lower permanent
premolars simultaneously with lower deciduous molars and
upper second molars instead of upper third molars. The
latter is particularly liable to occur if the upper third molar
is partially erupted and difficult to visualise.
Being aware of the possibility of these errors and
“counting out” the tooth to be extracted will go some way
to minimising their occurrence.
A common source of confusion is the correct identification
of one of 2 molar teeth when the other molar is missing or
absent. Although a naming convention exists for just this
situation, longhand notation such as “the first standing
lower right molar” instead of the lower right 7 may help
avoid confusion where the third molar is erupted and the
first molar is absent.
A similar situation occurs when only one of 2 unerupted
and adjacent teeth are to be extracted. Again, this is
commonly requested as part of an orthodontic treatment
plan and as such should be avoided at all costs.
If the wrong tooth is extracted, the oral surgeon should
proceed with removing the correct tooth unless the
extractions are for orthodontic purpose when it may be
better to seek the advice of the patients’ orthodontist first.
The tooth extracted in error, particularly if it is otherwise
healthy, should be immediately replaced in its socket. If
mobile, it should be held in place with a custom made
vacuum-formed splint for approximately 4 weeks. It is
likely that it will subsequently require to be root-filled and if
there is any doubt about its prognosis, the advice of a
consultant restorative dentist should be sought.
Fractured Upper / Lower Jaw secondary to Tooth
Removal. Incidence: 2 - 4% (including alveolar and lingual
plate fractures, so the incidence of actual fractures of the
upper and lower jaws is likely to be much less).
This is probably the most feared of all complications
following Minor Oral Surgery and like the majority of them
is largely preventable. It is a recognised complication of
lower wisdom tooth removal and should be listed as such
on a routine consent form.
Fracture of the mandible / lower jaw is a very unpleasant
but fortunately rare complication that is associated almost
exclusively with the extraction of impacted lower wisdom
teeth
There are a number of predisposing conditions, such as:
- use of excessive force with the elevator, when an
adequate pathway for removal of the impacted tooth
has not been created - mandibular atrophy
- deeply impacted tooth
- a tooth with firm anchorage
- extensive œdentulous regions
- an ankylosed tooth
- osteoporosis and
- the presence of associated pathology such as a cyst
or tumour.
When a fracture occurs during the extraction, the tooth
must be removed before any other procedure is carried
out, in order to avoid infection along the line of the fracture.
The fracture must be repaired if necessary - if the
operator is unable to do this, they must arrange an
immediate referral. Afterwards, depending on the case,
stabilisation by way of inter-maxillary fixation or rigid
internal fixation of the jaw segments is applied for 4 – 6
weeks and broad-spectrum antibiotics are administered.
Patients should be advised to consume a soft diet for
several weeks and to return immediately if they become
aware of any abnormalities in the jaw.
Fracture / Failure of Instrument with Retention of
Instrument Fragment within Bone / Soft Tissue. Any
broken instrument should be removed at the time of the
operation. If not retrievable, the patient should be told and
this recorded in the notes.
Suture needles, hypodermic needles and surgical burrs are
the items that most frequently fracture / fail in use. Suture
needles are probably the commonest items to be broken
during minor oral surgery.
As a general rule, all fragments of broken instruments
should be removed immediately before they have time to
migrate deeper into the tissues.
If the fragment cannot be found, radiographs in 2 planes at
90° should be taken of the operative area to locate it. At
this point, a decision will need to be taken as to whether to
remove the fragment or leave it in situ depending on its
size and site.
Small fragments lying sub-periostealy can be safely left as
they are unlikely to migrate and cause problems. If the
decision is taken to remove the fragment, the operative
approach will depend on where it is located and a
thorough knowledge of the local anatomy is essential if
further complications are to be avoided. It should be
remembered that small fine foreign bodies can be
extremely difficult to locate and that blind exploration of
tissue spaces is wont to displace them deeper. The use
of image intensification can be very helpful in this situation.
Breakage of an instrument in the tissues is the result of
excessive force during the removal of the tooth and usually
involves the end of the blade of various elevators or bur.
Breakage may be the result of repeated use of the
instrument altering its metallic composition (mainly of the
bur). In these cases, after precise radiographic
localisation, the broken piece(s) are removed surgically at
the same time as extraction of the tooth or root.
Soft Tissue Damage
- Mechanical Trauma
- Thermal Trauma
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