Complications during an extraction.
Even a simple extraction may get complicated for various reasons. Among these reasons there are anatomical influences (retention, a tooth’s bent, anomalous number of roots, hypercementosis of roots), uneasiness of a patient, unsatisfactory equipment of a dentist’s office etc. The most frequent complications are the following:
Breaking of a tooth’s crown, breaking an alveolus wall.
Luxation or sub-luxation of an adjacent tooth.
Opening of the maxillar sinus during extractions of premolars or molars in the upper jaw.
Injury of the mandibular nerve during difficult extractions of deeply positioned lower molars, eventually breaking the lower jawbone.
Breakage of an extracted tooth is quite common complication that requires finishing the extraction by surgical means. A surgical extraction starts by cutting the mucosa and the periosteum, and continues by forming so called mucoperiosteal flap. A cortical part covering the broken tooth’s root is removed by bone surgery instruments (chisel, hammer, milling cutter). The root is pulled up by extraction levers and after trimming the bone wound, edges of the mucosa are joined by a stitch.
Complications after an extraction.
Impaired healing of an extraction wound. Under physiological conditions, healing of an extraction wound is made by formation of a blood clot that fills an alveolus after a tooth has been pulled out. The coagulum changes into a granulating tissue that becomes ligamentous tissue in 3 to 4 weeks. Complete healing of a bone tissue takes around six months or more. This healing process may be hampered by absence of a blood clot at hemocoagulation disorders, or by washing off a coagulum during extensive mouth rinsing after an extraction, or by infection of a coagulum followed by its decay. This leads to the post-extraction syndrome , causing prolonged healing of an extraction wound. This syndrome has two forms:
Alveolitis sicca (dry socket) is caused by traumatization of tissues after a difficult extraction or by a tissue ischemia after the use of excessive amounts of an anesthetic. A sharp pain which shoots to temples, ears and cheeks, occurs the second or third day after an extraction. The alveolar socket is covered with a gray coat and its surroundings are red and painful.
Alveolitis purulenta (purulent alveolitis) is caused by infection and subsequent decay of a blood coagulum. It is characterized by a large general alteration, fevers, foetor ex ore and reaction of local lymph nodes. Therapy of an alveolitis tries to restore the physiological filling of the tooth’s bed by a blood clot after former wound excochleation. Rinsing the alveolus with solutions of a disinfectant (1%0 Rivanol) are used. For local therapy, drugs with analgesic effects (Pharodoran, Apernyl) or physical therapy (Solux lamp) are used. Currently, a biostimulating and analgesic effects of a laser have been used successfully. For general therapy, analgesic and antipyretic medications are administered. Antibiotics should be used only if there is a danger of spreading the alveolitis further (a possibility of osteomyelitis or jaws inflammation).
Bleeding after an extraction.
Bleeding from an extraction wound stops in 5-10 minutes under physiological conditions and the wound gets filled with a blood coagulum. Prolonged bleeding may be caused by local or general factors:
Local causes of bleeding can be numerous. It may be a granulous tissue inside en extraction wound, a root or its fragment after an unfinished extraction, foreign objects (pieces of metal fillings) in a wound, bruised mucous edges. Bleeding can also be provoked by irritation of the wound’s edges by tongue, excessive rinsing or sucking. More serious bleeding may occur in cases of angioma in the oral cavity or by damaging blood vessel branches by cutting, e.g. during incision of abscesses.
General causes of bleeding. Heavy bleeding may appear at patient with hypertension, respiratory tract diseases with a fever, when a permeability of blood vessel walls is increased due to infection. Diabetic angiopathies cause heavy bleeding at patients with diabetes. Menstruation tends to increase bleeding, so surgeries are not usually planned for this period. Bleeding disorders (coagulopathias such as hemophilia A, B, thrombopathia and purpuras of blood vessel types), anticoagulation therapy at patients after myocardial infarction, heart surgeries and thromboembolic diseases, belong to severe causes of post-extraction bleeding. As one can see from the above listed causes of post-extraction bleeding, a detailed anamnesis before a surgery itself is very important. In cases of general illnesses, a specialist’s opinion and recommended preparation of a patient are required. Bleeding disorders are an indication for a surgery in the inpatient care. In case an unexpected bleeding of unclear origin occurs after an extraction, a local wound dressing has to be made. It should start with a local anesthesia that enables for good overview of a bleeding wound and its painless revision. Remains of a granulous tissue, fragments of teeth and other foreign objects are removed from the alveolar socket by excochleation and bruised edges of a wound should be trimmed (the wound toilet). Sharp edges of the alveolus should be smoothened by a milling cutter providing a good cooling is ensured. Mucous margins are brought together by a stitch (“mattress stitch”). An absorbable hemo-styptic drug Traumacel in the powder form (Traumacel P) or dental suppositories have been used with good results. If bleeding does not stop upon this treatment, it is necessary to identify its cause and hospitalize a patient at a specialized department.
8.2 Diseases of the Mandibular Joint
The mandibular joint is a complicated structure of the oro-facial area and that is why diagnostics and therapy of its diseases are difficult. Several factors with potentially additive effects play a role at the origin of problems. Causes of joint difficulties are occasional or chronic traumas, recurring luxations, lowering of the vertical mutual position of jaws, psychogenic factors resulting in bruxism (grinding and clenching of the teeth) and muscular spasms, infectious diseases ( acute rheumatic disease), degenerative processes (osteoarthritis), congenital disorders (joint head hyperplasia) and others.
Among the clinical manifestations, the pain (arthralgia) at the mandibular joint area is on the first place. It is mostly localized directly inside the joint, it is either one-sided or double-sided and increases upon its function. Sometimes the pain gets transferred into a temple, ear or lower jaw. The joint sound effects - cracking and screeching during its movements - are very disturbing. These sounds can be often heard at a close distance from a patient. Another sign is a restricted mobility of the joint, associated with muscular spasms and tenderness of some of the chewing muscles (especially pterygoid muscles). This painful tension of chewing muscles is mostly felt by patients in the morning after waking up and it gradually decreases later during a day. If one observes a slow mouth opening movement at these patients, deviation from the center or S-like movement of the lower jaw can be noticed. Clinical examination should be completed by an X-ray exam of the mandibular joint. The described symptoms are typical for the syndrome of mandibular joint dysfunction and pain. This syndrome occurs preferably at young age (between 20 and 40 years), more often at women. A characteristic feature for its identification is a negative X-ray finding at bone structures of the mandibular joint. Therapy of the above problems is tedious and needs a patience. The basis of therapy is adjustment of articulation and occlusal malfunctions by an occlusion splint made of resin and 3-6 mm thick. After the difficulties diminish, the increase in height of the occlusion can be maintained by prosthetic treatment. Supplemental therapy includes symptomatic influencing of particular problems. It includes ionophoresis with Mesocain, Solux lamp, diadynamic currents, 1% Mesocaine shots in the area around the mandibular joint, transcutaneous neurostimulation (Analgonik).
Acute inflammations (arthritis) that appear during an acute rheumatic disease, general infectious diseases or by transfer of infection from adjacent areas undergo therapy according to general rules with use of antibiotics, analgesic and antiphlogistic drugs. A temporary immobilization of jaws is made with the aim of reducing pain at the time of movements. A puncture of the joint exudate is less common.
Osteoarthritis of the mandibular joint is a degenerative disease, even though it may originate from chronic traumatization of the joint structures at habitual or recurring luxations. Besides the corticoid therapy (Kenalog), a surgical extirpation of a threaded joint meniscus or the condylar process is performed in some cases.