Prevention, Diagnosis, and Management of Oral Surgery Complications

1. Prevention, Diagnosis, and Management of Oral Surgery Complications June 28, 2015 David Salehani, D.D.S., M.D. Private Practice, West Hollywood, CA UCLA Reagan Medical Center Faculty at UCLA School of Dental Medicine

2. Complications of Dentoalveolar Surgery • Proper treatment planning and sound surgical principles should lower the incidence of complications. • Incidence of complications associated with the removal of third molars, the most common dentoalveolar surgical procedure, is 7 to 10.8 percent. 2, 3

3. Complications of Dentoalveolar Surgery • Think ahead and have all proper instruments and medications available. • Proper surgical suction • Hemostatic agents (gelfoam, collaplug, etc.) • Sutures • Surgical blades • Surgical handpiece

4. Complications of Dentoalveolar Surgery

5. Complications of Dentoalveolar Surgery • To avoid complications: • Have all necessary radiographs for proper diagnosis. • Always have an unobstructed view and access in the presence of adequate light, proper soft tissue reflection, and adequate suction.

6. Complications of Dentoalveolar Surgery • Local anesthetics complications: • Rare • A more common adverse sequela: hematoma • PSA: rapid posterior buccal swelling • Pterygoid venous plexus: slower development • Treatment: • Direct pressure to the area • Cold packs for 24 hrs • Then heat to facilitate reabsorption

7. Complications of Dentoalveolar Surgery • Local anesthetics complications: (Cont’d) • More serious situation: IA artery hematoma • Can compromise the airway • Tx is directed at maintaining an airway, followed by local or systemic interventions if required.

8. Complications of Dentoalveolar Surgery • Local anesthetics complications: • Facial ecchymosis and discoloration:

9. Complications of Dentoalveolar Surgery • Local anesthetics complications: (Cont’d) • Inadvertent posterior injection into the parotid capsule: • Facial nerve palsy: • Reassure patient of the transient nature • Gauze patch over the affected eye

10. Facial Nerve Palsy:

11. Facial Nerve Palsy:

12. Complications of Dentoalveolar Surgery • Local anesthetics complications: (Cont’d) • Fracture of the needle within the tissues • No attempt to palpate the needle • Radiographs to orient the location in three planes

13. Complications of Dentoalveolar Surgery • Local anesthetics complications: (Cont’d) • It is reported that the needles do not frequently migrate through soft tissues to vital structures. • However, an attempt to retrieve the needle may be made to alleviate patient anxiety regarding subsequent injury • Weigh the risks and benefits of surgical exploration • Refer to a surgeon

17. Complications of Dentoalveolar Surgery • Local anesthetics complications: (Cont’d) • Nerve trauma: • Rare • Most common: IAN (1 in 400,000 to 1 in 750,000 cases) • Epineural hematoma • Direct needle trauma • Avoid excessive firm needle contact with the bone to prevent a needle barb. • Toxicity of local anesthetic • Reported that if spontaneous recovery has not been achieved within 21 days, the odds of its return are approximately 33%.

19. Complications of Dentoalveolar Surgery • Neurologic complications: • Sensory nerve damage • Usually associated with third molar surgery • Typically IAN • Less frequently lingual nerve • Rarely long buccal nerve • 0.6% to 5% of third molar cases • Spontaneous recovery in 96% of IAN cases • Spontaneous recovery in 87% of lingual nerve cases • Mostly in the first 6-8 weeks, remaining within 9 months • Total recovery after 9 months is rare.

20. Complications of Dentoalveolar Surgery • Neurologic complications: (Cont’d) • Patient Age: • Higher morbidity in patients older than 25 years

21. Complications of Dentoalveolar Surgery • Neurologic complications: (Cont’d) • Pre-op radiologic exam: (Panorex) • Cortical outline and location of the canal

32. Complications of Dentoalveolar Surgery • Paresthesia is one of the leading causes of liability against OMFS and has been among the top four in dollars awarded.

33. Complications of Dentoalveolar Surgery • Injuries to the lingual nerve: • 1% of lower third molar extractions • Most difficult for patients to accept because of altered taste sensation and reduced chance of recovery. • The lingual nerve may course over onto the retromolar pad. • It can be traumatized by incisions, retractions, flap elevation, tooth and follicle removal, and suturing.

34. Complications of Dentoalveolar Surgery • Injuries to the lingual nerve: • Unlike with IAN damage, reducing the incidence of lingual nerve injury is related to surgical technique. • If indicated , mandibular third molar suturing should be limited to the superficial tissues of the lingual flap to reduce trauma to the lingual nerve.

35. Complications of Dentoalveolar Surgery • Injuries to the lingual nerve: (Cont’d) • The return of sensation with the first 4 weeks: • Neuropraxia, excellent px • Symptoms of recovery manifesting at 1 to 3 months indicate a less certain px • Failure to exhibit recovery sypmtoms for 12 or more weeks indicates neurotmesis, poor px for spontaneous recovery

36. Complications of Dentoalveolar Surgery • Injuries to adjacent teeth and structures: • Iatrogenic luxation of adjacent tooth: • Assess the mobility of the tooth • Reposition the tooth • Take out of traumatic occlusion • Stabilize for 10-14 days

38. Complications of Dentoalveolar Surgery • Injuries to adjacent teeth and structures: • The use of exuberant force when extracting teeth is unnecessary. • Force must always be applied in a controlled manner, using surgical finesse. • The most common damage: fracture of the crown or the existing restoration (mostly with elevators while luxating)

39. Complications of Dentoalveolar Surgery • Injuries to adjacent teeth and structures (Cont’d): • During luxation with the elevator • Consider carious teeth or large restorations of adjacent teeth pre-op as potential risks. • Discuss with the patient as part of the informed consent form pre-op.

40. Complications of Dentoalveolar Surgery • Inadvertent removal of the wrong tooth: • Attention to detail (Time-Out) • Atraumatic removal of a wrong tooth: (if immediately identified) • Reimplant and stabilize • All other extractions should be delayed 4 to 6 weeks to allow assessment and prognosis of the reimplanted tooth

41. Complications of Dentoalveolar Surgery • Injuries to the opposing dentition: • Result of excessive traction forces and sudden release of the tooth • Can cause chipped or fractured tooth • Minimize tractional forces, use proper elevation • Inform the patient

42. Complications of Dentoalveolar Surgery • Pain and swelling: • Associated with all surgical procedures • Normal physiologic responses to surgical treatment • However, this does not preclude the surgeon from taking all necessary actions to lessen their severity. • Factors that may increase these complications: • Excessive operating time • Poor management of soft tissue • Inappropriate use of irrigation • Ignoring other basic surgical principles

43. Complications of Dentoalveolar Surgery • Swelling: • Steroid therapy should have maximal anti-inflammatory effects and minimal glucocorticoid and mineralocorticoid activity. • Two steroids, dexamethasone and betamethasone are the most popular. • Pre-op IV steroids and post-op oral steroids have the greatest effect in decreasing swelling. • The use of ice, which is a routine recommendation, was not demonstrated to be a considerable factor in decreasing post-op swelling.

44. Complications of Dentoalveolar Surgery • Pain: • An inevitable sequela of dentoalveolar surgery • Peak pain: early post-op period 3-5 hrs after surgery • Study: 97% of patients suffered their highest level of pain on the day of surgery

45. Complications of Dentoalveolar Surgery • Pain (Cont’d): • Associated with increased concentration of prostaglandins • Prostaglandin antagonists such as NSAIDs would be the most effective means of pain management. • Use longer-acting local anesthetics • Proper surgical technique: • Reflection of flaps • Management of soft tissue • Copious irrigation when using drills • Use of controlled forces

46. Complications of Dentoalveolar Surgery • Temporomandibular joint injury: • If mandible is placed in an open position for extended periods, certain degree of force will be transmitted to the TMJ. • Use bite blocks, support the mandible. • Most successfully managed by conservative measures (soft diet, moist heat, jaw rest, muscle relaxants, NSAIDs, and on rare occasions splint therapy. • Further work-up: if symptoms persist beyond two weeks • Discuss as part of the informed consent

47. Complications of Dentoalveolar Surgery • Displacement of teeth into anatomical spaces: • Can occur with excessive force • Use: • Adequate access and visualization • Controlled force • Removal of sufficient bone • Placement of finger or instruments as distal stop

48. Complications of Dentoalveolar Surgery • Displacement into infratemporal fossa: • Distoangular maxillary third molar • Excessive force, poor visualization, lack of distal stop • First locate the tooth (lateral and PA cephs) Possible locations: 1) infratemporal fossa 2) maxillary sinus 3) in the mouth /aspirated/ throat pack