OS Sheet #12 By D.S.C.08

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By the name of Allah
To refresh your memory, last lecture we talked about healing of extraction wounds “formation of blood clot, filling the socket, organization of the surface of the wound” these steps are of most important and you have to know them very well.
if all teeth are lost, resorbtion will be relatively fast at first then it becomes more slowly so when you perform a dental clearance you ask the patient to wait at least for a month to put a denture, to be sure that the period of quick resorbtion has passed.
Causes of delayed healing of extraction wounds:
1- Infection.
2- Prolonged bleeding due to a clotting defect.
3- Formation of oro-antral fistula.
4- Malignant tumor.
5- Radiotherapy.
6- Immunodeficiency, i.e. Diabetic patients, patients with autoimmune disease “SLE”.
7- Scurvy: is a disease resulting from a deficiency of vitamin C, which is required for the synthesis of collagen in humans “WIKI”
We also talked about complications of dental extraction:
• They could be localized or generalized.
• They could be intra-operative or post-operative
• They may be related to: surgeon factor, patient factor, surgery or instrumentation. These are of most important, once you are asked about any complication think about these factors.
Local complications:
1- Tooth fracture.
2- Jaw fracture:
a- Most commonly in isolated molar extraction: long standing isolated molars result in dense bone and that dense bone is formed in response to high masticatory forces. In other words, sclerotic bone has been formed surrounding the molar to withstand high forces. Or hyper-cementosed tooth, both are hard to be extracted, but what to do in such cases? We do a surgical extraction.
b- Buried tooth: because it weakens the jaw -just as in lower wisdoms- as they occupy the jaw, so if we got a lower wisdom with a thin mandible and the patient falls down, the mandible will fracture at the wisdom area. And also it’s a weak bone over there so if you use an excessive force you would end up with a fractured jaw.
c- Thin mandible- edentulous.
d- Excessive force.
3- Damage to soft tissue:
a- Instruments slips off the tooth
b- Lower lip may be crushed between the teeth
c- The handles of the forceps or pressure of the hand supporting the jaw can cause bruising.
Q: When we hold the elevator we might touch the soft tissue, how we could hold the elevator without damaging the soft tissues?
A: You have to hold the elevator in the right way; it should be parallel to the long axes of the tooth so forces won’t affect soft tissues that much. Also you should hold the handle correctly and apply enough support to completely control the procedure.
Up to here the revision of the last lecture ends, and now we start our lecture:
4- Opening of the maxillary antrum: well, this is a very common complication. The most common tooth to be associated with this complication is the upper 6, upper 7 and 5 to a lesser degree. Sometimes the impacted wisdom not the erupted one. And it’s associated with excessive force during the procedure, hyper-cementosed tooth or even ankylosed one “ankylosis is more common in black than white populations”.
It occurs in two conditions”
a- Clean opening: treatment depends on the size, if it’s 3mm “or up to 5 mm in the Dr. opinion” , it’ll undergo self healing “no treatment is needed” but you as a dentist gives the patient an anti-biotic and instructions as not to blow air or not to sneeze. But how the patient would not sneeze? I give him a decongestant i.e. vibrocil.

So again the blood clot will take care of the opening but we just have to be sure that the patient won’t sneeze by giving him a decongestant, then you ask the patient to come later and you check for the clot and other things as the health of the wound. But if it was more than 5mm, 1cm for example, and that could happens if the dentist was so aggressive and he removed the tooth with bone, we have to close the opening and that’s done by flap as it’s too hard to be closed by squeezing. The flap usually either buccal flap or palatal flap. So you make a flap –three incision flap for example- and you make serration in the periostium to become more flexible and then you approximate them “the walls of the opening” and the periostium will take care of the wound and form bone “you have to imagine actually how the periostium would cover the wound so we need it to be flexible and that’s why we makes serrations in it”.

Ps: you never remove all the buccal bone even if you have an impacted tooth, you can make a window in the bone “you really have to leave a bridge of cervical bone”, but removing all the bone means that no healing will occur ending with a sever condition.

An end of a long conversation, the Dr. stated that if you make an opening you just have to close it, how? This is not the topic of the lecture “it’s about complications not treatment of them”.

Ps: extraction of an ankylosed tooth is at higher risk of jaw fracture as also if it was hyper-cementosed than extraction of a normal tooth.
b- Opening with a trapped body: any foreign body in the sinus needs to be taken out. If u can see it, you have to pull it otherwise you have to open the sinus. And you have to know that the best treatment is the immediate one.
Q: why we can’t leave anything in the sinus?
A: because the sinus is contaminated, so any foreign body will be a good reservoir to the bacteria and that may lead to a serious complications
5- Fracture of the maxillary tuberosity: also very common. It occurs mostly when we extract a third molar or a second molar in the absence of the third. It’s also related to surgeon factors, patient factures and instrumentation. That’s why we do support, to feel what we are doing “the support doesn’t prevent the breakage of bone but it makes you feel that you had broken bone so you can deal with that”. So if you felt that bone is moving “you broke the bone”, it’s either that you broke a small piece or large piece. If it was a small piece, take it out with the tooth and give him anti-biotic. Otherwise you have to leave it to prevent further complications as it might be attached to a muscle or it passes near a vital structure. You try to fix it by means we are going to talk about them later on and suture any present lacerations and tell the patient that he should not eat on it, and you ask the patient to come after a three weeks or more to extract the tooth but this time you extracted by surgical means “surgical incision”.
6- Loss of tooth: if you find that you lost the tooth, look, because it may be on the ground and it’s not a must to be inhaled or swallowed.
But if it’s not on the ground, it may be:
a- In the tissues: Displaced into the loose tissue on the lingual side of the lower molar. once we found it, we have to take it out. If it wasn’t removed it would cause further complications like scares. It usually goes to the right lung.
b- Inhaled: if the patient is sleeping, mostly he will inhale the tooth. If it was inhaled, the Dr. must do a chest X-ray and if it’s in the lung we must send him to the medical surgeons and they would take care of him. And as you know it usually goes to the right lung.
c- Swallowed: if the patient is awake, mostly he will swallow the tooth. If it’s swallowed we give the patient laxative and it will come out alone.
So what to do is an immediate OPG and you always remember that the best chance is the first chance. And once we found it, we have to take it out.
7- Removal of permanent tooth germ: during extraction of a deciduous tooth with periapical leaion.
8- Excessive bleeding: a. Tissue damaged – careless extraction.
9- b. As a result of haemorrhagic disease. c. Infection.

10- Localized infection: Localised ostietis (dry socket) and osteomylietis.
11- Loss of root fragment:
a. Displaced into the inferior dental canal.
b. Displaced into the medullary cavity.
c. Displaced into the antrum.
d. Displaced into a cystic cavity.
Intra-operative complications:
1- Accessibility:
a- Small mouth.
b- Crowded or mall-positioned teeth. It’s not easy and it might need special tools.
c- Trismus
2- Pain: Depends on the efficiency of the anesthesia. Regional block – infiltration or inter-ligumentary.

3- Inability to move the tooth: in cases like:
X-Ray → :

a. Bulbous or diverging roots.
b. Very long roots.
c. Ankylosis or sclerotic bone.
4- Breaking the tooth or alveolar bone
Dry socket “alveolar osteitis”
• (The most frequent painful complication of extraction )
• It’s always prevention better than cure.
• Another Dr. will talk about this subject.

Indication for extractions: they’re very important
1. Gross caries.
2. Pulpitis (if endodontic treatment is impractical)
3. Apical periodontitis ( if the teeth are non savable )
4. Gross periodontal disease.
5. Fractured teeth.
6. Fractures of the jaw.
7. Misplaced and impacted teeth.
8. Orthodontic treatment.
9. Retained deciduous teeth.
10. Prosthetic considerations.
11. Supernumerary and supplemental teeth.
12. Gross neglect.
13. Patient at risk from certain systemic diseases: If a focal infection is suspected, the decision for or against extraction very much depends on the underlying disease. For example in cases of endocarditis, acute rheumatic fever or acute glomerulonephritis, removal of suspect teeth should be carried out without hesitation
14. Preparation for radiotherapy.

Causes of difficult extractions: also they’re of very importance
1. Excessively strong supporting tissues.
2. Misshapen roots.
3. Easily detached crowns.
4. Brittle teeth (Glass in concrete).
5. Sclerosis of the bone.
6. Burried and impacted teeth.
7. Ankylosis and geminated teeth.
8. Inadequate access.



What you see in the previous picture is a remaining root in the sinus “it’s just below the sinus floor”; the treatment was by doing a flap and pulling that root using a probe. It’s easy but if you leave it, it’ll go inside and it’ll be problematic. So you always remember, the first chance is the best chance.

This is cystic cavity, globule-maxillary cyst, if I extract this tooth or a remaining root it most probably will go inside without seeing it.

This isn’t a simple extraction as there’s a peri-apical cemental dysplasia “we diagnose it by doing a vitality test and we found the tooth vital” so we don’t extract the tooth in this case.


This is ossifying fibroma, the same with the vitality test.

This is exactly what would happen if you extract teeth for a patient had a radiotherapy or osteopetrosis. Poor blood supply and the dentist didn’t perform a surgical extraction. It’s an easy extraction but very poor prognosis. It’s treated by taking half of the mandible, till we reach a fresh blood. So if you face a patient like this, you have to perform a surgical extraction and a good wound closer because the blood supply depends on the periostium so we really have to preserve our periostium.


The previous 3 pictures: Cotton wool appearance on the X-ray, Paget disease, this would result in a complex extraction and may end up with fractured jaw.

The previous 2 pictures: osteosarcoma and its X-ray. Extraction of this tooth would lead to ulcerations and it awould be very difficult.
The final message: don’t extract a tooth without X-ray.

Oral surgery #12
Dr. Zyad Malkawi
Done by: D.S.C.08