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Dentoalveolar surgery: intra-operative soft-tissue complications

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Soft-tissue contusions, lacerations and abrasions

Caused by rough handling with a retractor, improper use of the instruments, the slide of a drill or a mur or the use of a separating disk without protection.
When a tooth is pulled or surgically extracted, the dentist’s attention is focused on the tooth, and the patient’s reactions are often dulled by anesthesia.
Contusions result in increased post-operative swelling and pain. They generally heal without complications.
The treatment of lacerations and abrasions consists of suturing and the application of ointments or rinsing solutions. The formulations used may contain sage or chamomile extract, prednisolone, anesthetics or panthenol or a combination of these agents.

Soft tissue burns (caused by diathermia or coagulation, hot manual instruments or similar)


Mild burns to the vermillion of the lips usually heal without complications when treated with an ointment dressing.
More severe burns within or beyond the vermillion of the lips can lead to scarring. A hydrocortisone-based ointment can prevent this.

Intra-operative bleeding


  • severe trauma
  • anatomic peculiarities
  • pathological changes (hemangioma)
  • hypertension
  • hemorrhagic diathesis

Hemorrhage types according to type of injured vessel

punctured vein continuous non-pulsatile flow of dark red blood
punctured artery rhythmically squirting, bright red blood
capillary bleeding diffuse seepage of blood


Treatment principle

Application of pressure or direct vessel closure; coagulative drugs may also be required depending on the severity of bleeding.
Selective substitution therapy for hemorrhagic diathesis should be left to a specialist.

Blood squirting from soft tissues
  • electro-coagulation
  • crosswise suture ligature of the vessel
Blood squirting from bone
  • absorbable hemostatic agents (for tamponade)
  • bone wax
  • friction lock
Diffuse hemorrhage
  • absorbable hemostatic agents (for tamponade)
Massive hemorrhage
  • Replace extracted tooth, if necessary (especially if a pre-operative not discovered bone hemangioma is supected).
  • The surgeon should manually apply continuous, uninterrupted pressure to the hemorrhage site by pressing on a tampon or gauze pad, until the patient has arrived at the hospital.
  • Call an ambulance immediately.


  • digital compression
  • at least 3 to 4 minutes (coagulation time)
  • if underlying bone is present

Bone wax

Friction locking of bone

Suturing, ligature

Hemostatic agents (hemostyptics)

Hemostatic agents for tamponade
  1. non-absorbable gauze strips (from gauze sponge)
  2. absorbable hemostatic agents
    • Oxycellulose
      Hemostasis is achieved by compression.
      Tabotamp – absorbable hemostatic agent
    • Collagen fleece
      Arrests bleeding and promotes coagulation; thrombocytes stick to the fleece and activate the coagulation cascade when factor XII comes in contact with the collagen.
    • Gelatin sponge
      Hemostasis is achieved by compression.
      Gelastypt – porcine gelatin sponge
Alpaslan et al. (1997) compared the biocompatibility of implanted oxycellulose, gelatin sponges, and collagen sponges in the soft tissues of rats. All of these materials were well tolerated and did not appear to either impair nor promote wound healing.

Fibrin glue


coagulation of tissue using high-frequency electric current

Inferior alveolar nerve injuries


  • nerve block anesthesia
  • direct sharp or blunt trauma:
    nerve injury due to slippage of the surgical drill; blunt trauma while dislodging a tooth with a dental elevator, caused either by the elevator itself or by the dislocated root; frequently direct relation between nerval structure and the roots or clasping of the nerval structure by the roots (especially if wisdom teeth are impacted)
  • wound infection


  • frequency of immediate post-operative dysesthesia after wisdom tooth extraction:
    0.4-5.5 % (Gülicher and Gerlach 2000)
  • frequency of permanent dysesthesia after wisdom tooth extraction:
    0-2.2 % (Gülicher and Gerlach 2000, Rood JP 1992)

Lingual nerve injuries


  • direct, sharp trauma, for example, by placing a retromolar incision too far lingual, or by allowing the drill to slip too far lingual
  • when using a raspatory after raising and retracting a lingual mucoperiosteal flap
    Blunt injury to the immediate epiperiosteal lingual nerve can be caused simply by raising the periosteum (Mason 1988).
    To prevent this, the periosteum should be excised only to the lingual border of the retromolar plateau and not any further caudal. This seems to be completely sufficient for preventing drill injuries while also preventing direct contact between the raspatory and the nerve (Gülicher and Gerlach 2000).
  • pressure from a tongue retractor whilst under sedation or general anesthesia


frequency of immediate post-operative sensory disturbances related to wisdom tooth extraction:
0.06-11.5 % (Gülicher and Gerlach 2000)

frequency of permanent sensory disturbances related to wisdom tooth extraction:
0-2 % (Gülicher and Gerlach 2000, Rood JP 1992)

Risk and prevention of lingual nerve lesions whilst removing wisdom tooth

Hägler and Reich (2002) reviewed the relevant literature.

Operative procedures

Comparison of the frequency of temporary and permanent lingual nerve damage independent of which protective measures were used

  Incidence of temporary nerve damage Incidence of permanent nerve damage
Lingual split technique 0.5% to 19.8% 0% to 0.1%
Vestibular bone removal 0% to 1.9% 0% to 0.8%

In most of the few comparative studies available, temporary lingual nerve damage was more frequently observed with the lingual split technique than when buccal bone was removed. With regard to permanent lingual nerve damage no recommendation can be given for either method due to the lack of statistical relevance in the present studies. Preferential use of vestibular bone removal to prevent temporary lingual nerve damage can be justified based on the available data.

Use of an instrument for lingual nerve protection

There seems to be a slightly higher risk of temporary neurological dysfunction with protective use of the raspatory than without it.

The rate of permanent nerve damage after such protective measures is particularly relevant when considering whether such measures are indicated.

Incidence of permanent nerve damage
  Without protective measures With protective measures
Vestibular bone removal 0% to 0.3% 0% to 0.6%

The difference is not statistically significant

The literature does not provide any clear evidence as to whether mucoperiosteal protection leads to a significant reduction of temporary and especially permanent lingual nerve injury; however, most authors recommend it.

If there is a high risk of direct and therefore probably permanent lingual nerve injury, the usual protective measure (insertion of a raspatory) increases the risk of temporary nerve damage while the risk of permanent nerve damage is practically no higher than with other measures.
Therefore, differential use of lingual nerve protection by inserting an instrument between the lingual periosteum and cortex may be justified in such high-risk cases. However, based on the literature alone, one cannot say that this procedure is essential.

Procedure for sensory disturbances or injuries of inferior alveolar and lingual nerve

Confirmed nerve dissection
  • Inform the patient.
  • documentation
  • Refer for primary treatment.
Equivocal nerve dissection
  • Inform the patient.
  • documentation
  • wait-and-see strategy possible
    If the sensory disturbances fail to resolve within 26 to 35 weeks, follow-up can be discontinued because spontaneous remission is very unlikely after six months (Hausamen et al. 2003; measurement of somatosensory evoked potentials = SSEPs)
  • secondary reconstruction
A joint statement of the German Society of Dental, Oral and Craniomandibular Sciences (DGZMK) and the German Society for Oromaxillofacial Surgery (DGMKG) precisely informs about the current legally applicable and relevant methods for differential treatment of lesions of the inferior alveolar and the lingual nerves (Hausamen JE, Hoffmeister B, Reich R. 2003).

Pre-operative patient information obligations

Pursuant to current legislation, there is a risk of damage to the inferior alveolar and the lingual nerves caused by regional block anaesthesia which is subject to pre-operative patient information. Regardless of this obligation, patients should always be informed, prior to surgery, about the risk of intra-operative nerve damage (for both nerve structures) in the course of extraction of wisdom teeth.

Duty to take due care

Before wisdom tooth extraction, pre-operative radiological diagnosis with complete coverage of the root apices is mandatory (Gaisbauer 1995).



  • Alpaslan C, Alpaslan GH, Oygur T (1997) Tissue reaction to three subcutaneously implanted local hemostatic agents Br J Oral Maxillofac Surg 35:129-32
  • Gaisbauer, G (1995) Zur Haftung des Zahnarztes für Nervenläsionen - Eine Rechtsprechungsübersicht VersR 95,12 VersR 1995, 12 (Heft 1/95)
  • Gülicher D, Gerlach KL (2000) Inzidenz, Risikofaktoren und Verlauf von Sensibilitätsstörungen nach operativer Weisheitszahnentfernung. Untersuchung an 1106 Fällen Mund Kiefer Gesichtschir. 2000 Mar;4(2):99-104
  • Hägler G, Reich RH (2002) Risk and prevention of lesions of the lingual nerve in wisdom tooth osteotomy. Analysis of the literature and faculty opinion in maxillofacial surgery in German-speaking countries, Mund Kiefer Gesichtschir. 2002 Jan;6(1):34-9
  • Hausamen JE, Reich R, Hoffmeister B, (2003) Differentialtherapie nach Läsionen des N. alveolaris inferior und N. lingualis, gemeinsame Stellungnahme der DGZMK und DGMKG, DZZ 08 (03)
  • Mason DA (1988) Lingual nerve damage following lower third molar surgery Int J Oral Maxillofac Surg 17:290-4
  • Rood JP (1992) Permanent damage to inferior alveolar and lingual nerves during the removal of impacted mandibular third molars. Comparison of two methods of bone removal Br Dent J. 1992 Feb 8;172(3):108-10