Complications of Extractions

The many risks and considerations involved when performing an extraction can present a particular challenge to the dental professional, especially regarding management of bleeding. Many factors can increase the potential difficulty of an extraction, including difficult root morphology and some inflammatory disorders, but with a thorough medical history, a complete pre-operative examination, and adherence to proper surgical guidelines, complications can be kept to a minimum. Due to the high vascularization of the head and neck region, bleeding is a normal and expected part of the extraction process, but precautions must be taken to avoid hemorrhage. Hemostatic agents such as absorbable gelatin sponge, topical thrombin, and/or oxidized regenerated methylcellulose are frequently used to manage post-operative bleeding. Secondary bleeding, delayed healing, and dry socket are all common complications of extractions, although of these, dry socket is usually the primary cause for concern. A variety of methods for preventing and treating dry socket are discussed and evaluated in this article. Introduction Careful evaluation and planning reduce risks. The standard of care requires a thorough medical history prior to performing any surgery, including prior medical and dental history, prior surgeries, and pharmacology therapy. For high-risk patients, a consultation should be obtained with the patient’s healthcare providers. As a surgeon, you must always follow proper surgical techniques. You need to know your limitations prior to beginning any extraction and consider referring to a specialist if confronted with a case beyond your experience. Should you find yourself in a situation in the middle of a case; pause, take a deep breath, and carefully review all your options. At times, discretion is the better part of valor, and it is best to stop. Continuing to chase root tips could lead to additional and more involved surgery, or could invade the sinus, the neurovascular bundle, or other vital anatomic structures. It is best to stop and temporize, carefully explain the situation to the patient, and refer to a specialist for completion of the procedure. Factors That Tend to Increase the Difficulty of Extractions A careful pre-operative evaluation is also mandated by the standard of care. This includes a thorough physical examination as well as a complete radiographic examination. X-rays should demonstrate the entire tooth and surrounding anatomy. Do not accept cone-cut or improperly processed films. Use panoramic or extra-oral radiographs when intra-oral films are nondiagnostic. Carefully review the films pre-operatively. Take particular note of features such as: 1. Difficult root morphology (divergent, hooked, locked, ankylosed, geminated, misshapen, or exhibiting hypercementoses); 2. Teeth containing weakened coronal surfaces due to large restorations; 3. Teeth that have been abraded or exhibit fractures or deep caries; 4. Desiccated or brittle teeth associated with endodontic treatment; 5. Inflammatory disorders associated with alveolar bone, including Paget’s disease; and 6. Radionecrotic bone caused by radiation therapy. Normal Healing Process Immediately after teeth are extracted, blood flowing from alveolar bone and gingiva begins to clot. The clot prevents debris, food, and other irritants from entering the extraction site; protects the underlying bone; and acts as a supporting system in which granulation tissue develops. Tissue damage provokes the inflammatory reaction, causing the vessels of the socket to expand. Leucocytes and fibroblasts invade from the surrounding connective tissues until the clot is replaced by granulation tissue. Leucocytes gradually digest the clot, while epithelium begins to proliferate over the surface during the second week post-operatively. This eventually forms a complete protective covering. During this time, there is an increased blood supply to the socket, which is associated with resorption of the dense lamina dura by osteoclasts. Small fragments of bone that have lost their blood supply are encapsulated by osteoclasts and eventually pushed to the surface or resorbed. Approximately one month after an extraction, coarse woven bone is laid down by osteoblasts. Trabecular bone then follows, until the normal pattern of the alveolus is restored. Finally, compact bone forms over the surface of the alveolus, and remodeling continues. Bleeding Challenges The high vascularization of the head and neck region is both friend and foe to the dental surgeon. The increased blood sup-