OS Sheet #11 By Danah Kanaan

http://www.mediafire.com/?fsfhhylenk8vcmm

23-Dec-11
Lec. # 13
Dr. ziad milkawi



Prevention & management of extraction complications

We’ll start by talking a little bit a bout healing.
-Blood clot formation  epithilialization  organization

- Delayed healing
The Dr.gave us a clinical situation that he faced where a patient came complaining from malocclusion (his teeth wont close together), the patient had gone through extraction of a lower wisdom, but the patient came back complaining that the wound didn’t heal so the surgeon extracted the lower 7, but after that the wound still didn’t heal and the patient encountered malocclusion. After examination it appeared that he had a fractured jaw, not due to excessive force during extraction since it is an easy case but because the patient had gone radiotherapy.
He had osteoradionecrosis so no good healing would occur.
When the Dr. examined the patient his face appeared as if burned due to overdose of radiotherapy; so examination and medical history are very important.


What happens in radiotherapy is that it causes edarteritis obliterans which is prolifration in the intima of the artries jeopardizes the blood supply so no good healing can occur, these cases need special management

Other cases which lead to poor healing:
- oroantral fistula
- tumors ( intra alveolar carcinoma)
e.g. if a patient with good oral hygiene comes complaining from a single mobile tooth with no periodontal problems, we have to take a panorama first not direct extraction , if there was a tumor we are supposed to find irregular radiolucency around the tooth.
In this case we shouldn’t extract the tooth to avoid dissemination of the tumor, and we do biopsy.

- some drugs such as bisphosphonate ( which is a drug taken by some women for osteoporosis but it causes osteochemonecrosis)
E.g. a patient came with no osteoporosis but was taking this drug to prevent osteoporosis as she believed , she had gone through an extraction procedure but the wound didn’t heal so the dr. put her under GA and preformed curettage, her bone was type IV **(/ 10 mm or less) and the problem with this bone is that its very fragile.
So what this drug does is very similar to radiotherapy, it causes arteritis obliterans ONLY in the head and neck area.
The effect of radiotherapy and bisphosphonate is irreversible, that means even if u stop them the effect will persist


*Proper steps for extraction:
1. proper history
2. examine the patient thoroughly
3. further special investigation
4. proper extraction


*complications faced during extractions

a) hard tissue  fracture of the tooth
b) soft tissue  laceration


*main components associated with extraction complications

1. surgeon

2. technique/instruments
(Using the wrong forceps, excess force)
An e.g. on both the surgeon and technique, a patient came to extract a tooth after a couple of hours he came back still bleeding, the dr. who extracted the tooth just gave another gauze, after a while the patient started going into hypovolimic shock and went to the hospital, after examining the patient the source of bleeding was laceration sublingually due to traumatic extraction, and proper suturing was it what it needed, this patient could have died if he hadn’t come back on the right time.

3. patient
If he is diabetic, has gone through radiotherapy…etc


*We can have
1. Systemitic complication: involving the whole body
2. Local complication: as the one mentioned above


*We can also classify complications as

1. Immidiate: occurs directly during the procedure
2. Intermediate: occurs hours to few days after the procedure
3. Delayed: occur a couple of days after the procedure such as infection

* Note: if the infection happened after a couple of days after the operation then most likely it’s due to an untreated blood clot


*** management :
Now in the cases with endarteritis oblitarans regardless of the cause, we need each drop of blood in that area, and here the patient is dependant of the periostiam for blood supply so we should do minimal invasive procedure and that’s by gingival flap & not leaving the socket open.

When a patient that has gone radiotherapy comes to the management is dose dependant; the maximum dose id 50 exposures; if the patient has gone through that DON’T touch him, we leave his teeth as roots & smoothen them

With bisphosphonate the maximum dose is > 30 units systematically

When extracting to elderly patients(age) the complication is delayed healing due to obliteration in the blood supply, if fracture occurs it won’t heal so we must be very careful.

• some tips about the safe instruments to use to avoid complications:
- the forceps that can be used to extract any tooth are the upper premolars’ forceps
- the best elevators after the coplent is the werk james
- Upper wisdoms always extracted using the werk James; it helps in detachment of the gums and mobility of the tooth.
- Using a craier in extracting the upper wisdoms especially if the movement of the hand is not controlled can lead to fracturing the max tuberosity.


In conclusion we should:
1. do an atrumatic surgery
2. save the periostium
3. close the wound


** Note:
There are 4 types of bone:
I. mainly cortical and less medullary bone as in the mandible
II. less cortical and more medullary
III. the medullary bone is more dominant
IV. mainly medullary bone, very little cortical




Done by : Danah kanaan