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Be prepared!

Complications of oral surgery, common pitfalls and managing them by Julie Cross

It is important to be prepared for the possibility of oral surgery procedures in practice. Indeed, access to a basic surgical kit is essential. Dental extractions are one of the most common oral surgery procedures carried out by GDPs.

With patients retaining their dentition for longer and often having extractions later in life, the procedure can pose more of a challenge than ever before.

Teeth that are more heavily restored, root treated and surrounded by dense bone, increase the likelihood of surgery so warn the patient of this possibility. Unfortunately, fracturing a tooth during extraction is common, too, and the secret to managing the situation is all in the planning:
Get a mapJulie Cross
Take a radiograph to assess the morphology of the retained root, the proximity of anatomical structures and any underlying pathology.

Surgical extraction of teeth
Flap design
Consider the anatomy and potential complications and think about the post-operative aesthetics in relation to the adjacent teeth. The size of the flap should be designed to allow good access for instruments.

Soft tissue surgical or bone removal
Raising a flap may give adequate access for luxators, elevators or forceps without the need for bone removal. However, if there is no application point for these instruments, then bone removal will be required. When removing bone, the clinician should ensure a retractor is used to protect the soft tissues from trauma. Using a retractor also allows a better view of – and easy access to – the surgical site.

Elevators and luxators
Elevators provide an application point for forceps or to move teeth prior to using forceps. They can also be used to remove teeth or retained roots or apices. Luxators are used to create space between a root and supporting bone for the application of elevators or forceps. Care should be taken, particularly in the maxillary posterior region, as tooth fragments can be pushed upwards and into the sinus.

Socket debridement and closure
Once the roots or teeth have been removed, the socket should be debrided and granulation tissue removed. If the bony socket is sharp or rough, smooth it to prevent trauma to the Julie Cross mucosa during healing.

Soft tissue damage
Mucosal tears can occur due to slipped instruments or forceps incorrectly positioned on the lingual or buccal tissues. These may require suturing and, in such situations, the clinician should always inform the patient. 

Root displaced into maxillary
antrum If a root has been displaced into the maxillary sinus during an extraction, the patient should be informed and it may mean referral to a maxillofacial or oral surgery department. 

Oro-antral communication following extraction
If the communication is small and the sinus lining is intact, this can be managed conservatively. The patient should be prescribed antibiotics and given nose-blowing instructions. A review should be arranged to ensure healing. If the communication is larger – or the lining is torn – then this will also require closure. 

Fractured tuberosity
Fractured tuberosities occur when removing maxillary wisdom teeth or lone-standing maxillary molar teeth. Lack of alveolar support during extraction increases the risk. If the tooth and fractured tuberosity are minimally displaced, then a splint can be used to support the fracture and allow healing
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