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| IMC Wiki | Dentoalveolar surgery: post-operative complications involving the bone

Dentoalveolar surgery: post-operative complications involving the bone

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Sharp edges of bone

Sharp bony edges of the alveolar margins or residual bone septa mainly cause pain and discomfort, but occasionally lead to perforations.
Treatment
surgical smoothing of the bone edges
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Mandibular fracture

Temporal aspects

The first week after tooth extraction seems to be the critical phase for fracture occurrence (Iizuka et al. 1997).
#pic# #pic#

Causes

  • use of excessive force during tooth extraction
  • mandibular atrophy
  • inadequate exposure or dissection of the tooth
  • severe weakening of the tooth during extraction
  • failure to comply with instructions regarding a soft diet (Perry and Goldberg 2000)
  • Most post-extraction fractures occur in teeth with either partial or total impaction of the tooth and a narrow space in the retromolar region (Iizuka et al. 1997).
  • Patients over 40 years of age are a risk group (Iizuka et al. 1997, Krimmel and Reinert 2000).

Symptoms and signs

The patient reports hearing a "cracking" sound from the jaw region while eating.
#pic# #pic#

Pre-operative patient information obligations

It is required by law to inform the patient that mandibular fracture is a potential complication of wisdom tooth extraction (OLG Düsseldorf 1997, OLG Munich 1996).

Alveolitis/post-extraction pain

Synonyms (von Arx 1996)

  • post-extraction pain
  • alveolitis sicca dolorosa
  • post-extraction osteitis
  • post-extraction syndrome
  • dry socket
  • (localized) alveolar osteitis
  • fibrinolytic alveolitis

Incidence

The incidence of alveolitis ranges between 2.4 % and 8.2 % based on studies of extractions in all tooth groups (Klammt and Schubert 1986).

Uncomplicated course of wound healing after tooth extraction

  • The root surface of the extracted tooth provides a measure of the size of the wound surface.
  • A 0.2 to 0.5 mm band of necrosis develops along the margins of the empty alveolus.
  • Neutrophilic granulocytes collect and form a wall of demarcation below the necrotic zone.
  • Mononuclear phagocytes later enter and begin to degrade the necrotic material.

Complicated course of wound healing

  • A blood clot cannot develop or dissolves.
  • Portions of the alveolar bone are exposed and develop necrotic zones of various depths.
  • The dying tissue and the rest of the clot provide an ideal breeding ground for bacteria.
  • The infection results in inflammation.
  • Absorption and repair processes require more time than in uncomplicated healing and involve a broader tissue zone.
  • Even small nerve endings and the inferior alveolar nerve in the mandible are thereby irritated directly or indirectly through metabolic reactions.
  • Healing can only occur after recovery from the infection and after degradation of the necrotic material by secondary intention.

Clinical features of alveolitis

  • symptom-free period 1 to 3 days after extraction
  • unbearable, usually throbbing pain from the extraction wound that radiates to the ear and temporomandibular joint region or to the eyes and temples
  • The extraction alveolus is empty or contains a putrid viscous mass (decomposing clot).
  • putrid halitosis
  • pain on pressure and enlargement of regional lymph nodes
  • decreased general condition with or without fever
  • absence of swelling
  • absence of trismus

Multifactorial etiology of alveolitis

development of alveolitis:
  • no primary blood clot formation in the alveolus, or
  • secondary decomposition of the clot
causes:

Gender/Oral contraception
The use of oral contraceptives is associated with a significantly higher risk of alveolitis (Cohen and Simecek 1995).
The higher the estrogen dose, the stronger the stimulation of fibrinolysis.
The risk of alveolitis can be lowered significantly by performing the extraction procedure in the pill-free period (days 22-28 of the menstrual cycle) (Catellani et al. 1980).

Fibrinolysis
Local, not systemic fibrinolytic activity plays an important role in the development of alveolitis.
Inflammation of the medullary spaces of the alveolar bone (caused by bacteria, saliva, trauma) stimulates the release of tissue activators.
These tissue activators convert plasminogen to plasmin, thereby triggering fibrinolysis of the blood clot.
Bradykinin, a tissue hormone with a strong pain component, is released during fibrinolysis (Birn 1972).

Smoking
Several studies have documented a higher incidence of alveolitis in smokers than in non-smokers (Larsen 1992).

reasons why smoking increases the incidence of alveolitis:
  • contamination of the extraction wound with foreign substances
  • dislodgement of the blood clot due to suction pressure in the oral cavity during smoking
  • nicotine stimulates the local release of noradrenaline (norepinephrine), thus leading to vasoconstriction of the peripheral vessels with a predilection for blood clot formation
  • reduced oxygen saturation in the blood due to carbon monoxide binding
Infection
pathogenesis
  1. direct destruction of the blood clot due to bacterial infection
  2. fibrinolysis of the blood clot secondary to bacteria-induced release of tissue factors
The following conditions significantly increase the incidence of alveolitis:
  • poor oral hygiene (large number of aerobic and anaerobic bacteria before surgery) (MacGregor and Hart 1970)
  • pre-existing peri-coronitis (Meyer 1971)
  • therapeutic indication for extraction (al-Khateeb et al. 1991)
  • reactivation of herpes simplex virus due to iatrogenic nerve injury during extraction (Hedner et al. 1993)
Insufficient primary blood clot formation
The poorer the blood filling of the alveolus, the higher the incidence of alveolitis (Meechan et al. 1988).

decreased filling of socket with blood:
  • smoking
  • major extraction trauma
  • filling generally lower in the maxilla than in the mandible
Mechanical clot destruction

Tooth location and size
The risk of alveolitis is higher in the mandible than in the maxilla.
The larger the wound surface (tooth root surface), the higher the risk of alveolitis.

Extraction or surgical trauma
The longer the duration of surgery or the more severe the surgical trauma, the higher the risk of alveolitis.

consequences of major extraction trauma (Meechan et al. 1988):
  • destruction of bone-borne periodontal tissues
  • destruction of reparative cells
  • release of chemical mediators of inflammation
  • reduced post-operative blood filling of the alveolus because of damage to alveolar blood vessels
Skill of the operator
When surgical wisdom tooth extraction is performed by an experienced surgeon, the risk of post-operative alveolitis is lower than when performed by an inexperienced surgeon.

Use of vasoconstrictors
The use of vasoconstrictors has no influence on the incidence of alveolitis.
Vasoconstrictor use is only short-term and, when discontinued, results in reactive vasodilatation.

Alveolitis prevention

  • remove the tooth in the absence of inflammation whenever possible
  • early decision for surgical removal (flap procedure) after complicated extractions
  • prophylactic removal of wisdom teeth before they erupt

Chlorhexidine

The use of chlorhexidine (0.12–0.2 %) before and/or after extraction significantly reduces the risk of alveolitis.
Bacteria seem to be essential for the development of alveolitis; this factor can be reduced or eliminated by local treatment measures (von Arx 1996).

Antibiotics

Systemic or local administration of antibiotics reduces the risk of alveolitis.
The prophylactic use of antibiotics should be reserved for patients at risk for different reasons (sensitization, development of resistance, side effects, economic factors).

Treatment of open or incompletely closed wounds after lower wisdom tooth extraction

packing with Iodoform gauze packing stripes

Treatment of alveolitis

The extremely severe pain of alveolitis calls for treatment strategies with primarily analgesic effects.
The pain will subside once the exposed alveolar wall has been covered by granulation tissue.
Zinc oxide eugenol (ZOE) fillings quickly alleviate pain but slow down the healing process.

immediate treatment with zinc oxide eugenol gauze compresses
  • curette the alveolus under local anesthesia
  • rinsing with 1.5 % hydrogen peroxide solution (H2O2)
  • dry the alveolus thoroughly with a pledge
  • insertion of a gauze strip impregnated with zinc oxide eugenol in the upper half of the alveolus
  • pressure on the gauze strip for 30 minutes
  • change the strip after 5 to 7 days
If the symptoms do not improve within the next 2 days, surgical revision can be considered.


sources

  • al-Khateeb TL, el-Marsafi AI, Butler NP (1991) The relationship between the indications for the surgical removal of impacted third molars and the incidence of alveolar osteitis J Oral Maxillofac Surg.49:141-5
  • Birn H (1972) Fibrinolytic activity of alveolar bone in
  • Catellani JE, Harvey S, Erickson SH, Cherkin D (1980) Effect of oral contraceptive cycle on dry socket (localized alveolar osteitis) J Am Dent Assoc. 101:777-80
  • Cohen ME, Simecek JW (1995) Effects of gender-related factors on the incidence of localized alveolar osteitis Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 79:416-22
  • Hedner E, Vahlne A, Kahnberg KE, Hirsch JM (1993) Reactivated herpes simplex virus infection as a possible cause of dry socket after tooth extraction J Oral Maxillofac Surg. 51:370-6
  • Iizuka T, Tanner S, Berthold H (1997) Mandibular fractures following third molar extraction. A retrospective clinical and radiological study Int J Oral Maxillofac Surg. 1997 Oct;26(5):338-43
  • Klammt J, Schubert F (1986) Untersuchungen zum Zusammenhang von Alveolitis nach Zahnextraktion und Extraktionstrauma Dtsch Z Mund Kiefer-Gesichts-Chir 10:135-137
  • Krimmel M, Reinert S (2000) Mandibular fracture after third molar removal J Oral Maxillofac Surg. 2000 Oct;58(10):1110-2
  • Larsen PE (1992) Alveolar osteitis after surgical removal of impacted mandibular third molars. Identification of the patient at risk Oral Surg Oral Med Oral Pathol. 73:393-7
  • MacGregor AJ, Hart P (1970) Bacteria of the extraction wound J Oral Surg. 28:885-7
  • Meechan JG, Macgregor ID, Rogers SN, Hobson RS, Bate JP, Dennison M (1988) The effect of smoking on immediate post-extraction socket filling with blood and on the incidence of painful socket, Br J Oral Maxillofac Surg. 26:402-9
  • Meyer RA (1971) Effect of anesthesia on the incidence of alveolar osteitis J Oral Surg. 29:724-6
  • Perry PA, Goldberg MH (2000) Late mandibular fracture after third molar surgery: a survey of Connecticut oral and maxillofacial surgeons J Oral Maxillofac Surg. 2000 Aug;58(8):858-61
  • von Arx, T (1996) Alveolitits/Dolor post extractionem Acta Med Dent Helv 1:141-153