Prevention and Management of Surgical Complications
Larry J. Peterson
PREVENTION OF COMPLICATIONS INJURIESTO OSSEOUS STRUCTURES SOFT TISSUE INJURIES Fracture of Alveolar Process Tearing Mucosal Flap Fracture of Maxillary Tuberosity Puncture Wound of Soft Tissue INJURIESTO ADJACENT STRUCTURES Stretch or Abrasion Injury Injury to Regional Nerves COMPLICATIONS WITH THE TOOTH BEING EXTRACTED lnjury to Temporomandibular Joint Root Fracture OROANTRAL COMMUNICATIONS Root Displacement POSTOPERATIVE BLEEDING Tooth Lost into Oropharynx DELAYED HEALING AND INFECTION INJURIESTO ADJACENT TEETH Infection Fracture of Adjacent Restoration Wound Dehiscence Luxation of Adjacent Teeth Dry Socket Extraction of Wrong Teeth FRACTURES OF THE MANDIBLE SUMMARY
his chapter discusses the variety of complica- plications occasionally occur. In situations in which the tions of oral surgical procedures. It is divided dentist has planned carefully, the complication is often into two sections, intraoperative and postopera- expected and can be managed in a routine manner. For tive complications. These aye surgical, not medical, com- example, when extracting a maxillary first premolar, plications; the latter are discussed in Chapter 3. which has long thin roots, it is far easier to remove the buccal root than the palatal root. Therefore the surgeon uses more force toward the buccal root than toward the palatal root. If a root does fracture, it i~ then the buccal It is axiomatic that the best and easiest way to manage a root rather than the palatal root, and the subsequent con~plicationis to prevent it from happening. Prevention retrieval is easier. of surgical complications is best accomplished by a thor- Surgeons must perform surgery that is within their ough preoperative assessment and comprehensive treat- own ability. Surgeons must therefore carefully evaluate ment plan. Only when these are routinely performed can their training and ability before deciding to perform a the surgeon expect to have minimal complications. It is specific surgical task. It is inappropriate for a dentist with important to realize that even with such planning, com- limited experience in the management of impacted third 222 PART I1 m Principles of Exoriontin
molars to undertake the surgical extraction of a deeply embedded tooth. The incidence of operative and postoperative compli- Prevention of Soft Tissue Injuries cations is unacceptably high in this situation. Surgeons must be cautious of unwarranted optimism, which 1. Pay strict attention to soft tissue inju, ,,,. clouds their judgment and prevents them from deliver- 2. Develop adequate-sized flaps. ing the best possible care to the patient. The dentist must 3. Use minimal force for retraction of soft tissue. keep in mind that referral to a specialist is an option that should always be exercised if the planned surgery is beyond the dentist's own skill level. In some situations this is not only a moral obligation but also a medicole- gal responsibility. SOFT TISSUE INjURIES In planning a surgical procedure, the first step is Injuries to the soft tissue of the oral cavity are almost always a thorough review of the patient's medical histo- always the result of the surgeon's lack of adequate atten- ry. Several of the complications to be discussed in this tion to the delicate nature of the mucosa and the use of chapter are caused by inadequate attention to medical excessive and uncontrolled force. The surgeon must con- histories that would have revealed the presence of a com- tinue to pay careful attention to the soft tissue while work- plicating factor. Patients with compromised physical sta- ing primarily on the bone and tooth structure (Box 11-1). tus will have local surgical complications that could have been prevented had the surgeon taken a more thorough medical history. Tearing Mucosal Flap One of the primary ways to prevent complications is The most common soft tissue injury is the tearing of the by taking adequate radiographs and reviewing them care- mucosal flap during surgical extraction of a tooth. This is fully (see Chapter 7). The radiograph must include the usually the result of an inadequately sized envelope flap, entire area of surgery, including the apices of the roots of which is retracted beyond the tissue's ability to stretch the teeth to be extracted and the local and regional (Fig. 11-1). This results in a tearing, usually at one end of anatomic structures, such as the maxillary sinus and the the incision. Prevention of this complication is twofold: inferior alveolar canal. The surgeon must look for the (1) create adequately sized flaps to prevent excess tension presence of abnormal tooth root morphology. After care- on the flap, and (2) use small amounts of retraction force ful examination of the radiographs, the surgeon must on the flap. If a tear does occur in the flap, the flap should occasionally alter the treatment plan to prevent the com- be carefully repositioned once the surgery is complete. In plications that might be anticipated with a routine for- most patients, careful suturing of the tear results in ade- ceps (closed) extraction. Instead, the surgeon should con- quate but delayed healing. If the tear is especially jagged, sider surgical approaches to removing teeth in such cases. the surgeon may consider excising the edges of the torn After an adequate medical history has been taken and flap to create a smooth flap margin for closure. This lat- the radiographs have been analyzed, the surgeon must do ter step should be performed with caution, because exci- the preoperative planning. This is not simply a prepara- sion of excessive amounts of tissue leads to closure of the tion of a detailed surgical plan but is also a plan for man- wound under tension and probable wound dehiscence. aging patient anxiety and pain and postoperative recov- If the area of surgery is near the apex of a tooth, an ery (instructions and modifications of normal activity for increased incidence of envelope-flap tearing exists as a the patient). Thorough preoperative instructions and result of excessive retractional forces. In this situation a explanations for the patient are essential in preventing release incision to create a three-cornered flap should be the majority of complications that occur in the postoper- used to gain access to the bone. ative period. If the instructions are not thoroughly explained or their importance made clear, the patient is Puncture Wound of Soft Tissue less likely to follow them. Finally, to keep complications at a minimum, the sur- The second soft tissue injury that occurs with some fre- geon must always follow the basic surgical principles. quency is inadvertent puncturing of the soft tissue. There should always be clear visualization and access to Instruments, such as a straight elevator or periosteal ele- the operative field, which requires adequate light, ade- vator, may slip from the surgical field and puncture or quate soft tissue reflection (including lips, cheeks, tongue, tear into adjacent soft tissue. and soft tissue flaps), and adequate suction. The teeth to Once again, this injury is the result of using uncon- be removed must have an unimpeded pathway for trolled force instead of finesse and is best prevented by removal. Occasionally, bone must be removed and teeth the use of controlled force, with special attention given to must be sectioned to achieve this goal. Controlled force is the supporting fingers or support from the opposite hand of paramount importance; this means "finesse," not in anticipation of slippage. If the instrument slips from "force." The surgeon must follow the principles of asepsis, the tooth or bone, the fingers thus catch the hand before atraumatic handling of tissues, hemostasis, and thorough injury occurs (Fig. 11-2). When a puncture wound does debridement of the wound after the surgical procedure. occur, the treatment is aimed primarily at preventing Violation of these principles leads to an increased inci- infection and allowing healing to occur, usually by sec- dence and severity of surgical complications. ondary intention. If the wound bleeds excessively, it PrcJifrrltioil(711~1 Marln~yeinerlt of S~rr~picnlCornplicatior1.s m CHAPTER 11 223
FIG. 11-1 Periosteal elevator (Seldin elevator) is used to reflect mucoperiosteal flap. Elevator placed perpendicular to bone and held in place by pushing firmly against bone, not by push- ing it apically against soft tissue (arrow). should be controlled by direct pressure on the soft tissue. Once hemostasis is achieved, the wound is usually left open and not sutured, so that if a small infection were to occur, there would be an adequate pathway for drainage.
Stretch or Abrasion Injury Abrasions or burns of the lips and corners of the mouth are usually the result of the rotating shank of the bur rub- bing on the soft tissue (Fig. 11-3). When the surgeon is focused on the cutting end of the bur, the assistant should be aware of the location of the shank of the bur in relation to the cheeks and lips. If such an abrasion does develop, the dentist should advise the patient to keep it covered with Vaseline or an antibiotic ointment. It is important that the patient keeps the ointment only on the abraded area and not spread onto intact skin, because it is quite likely to result in a rash. These abrasions usually take 5 to 10 days to heal. The patient should keep the area moist with the ointment during the entire healing period to pre- vent eschar formation, scarring, and delayed healing, as well as to keep the area reasonably comfortable.
COMPLICATIONS WITH THE TOOTH BEING EXTRACTED
Root Fracture FIG. 1 f -2 Small straight elevator can be used as shoehorn to lux- The most common complication associated with the ate broken root. When straight elevator is used in this position, hand tooth being extracted is fracture of its roots. Long, must be securely supported on adjacent teeth to prevent inadver- curved, divergent roots that lie in dense bone are most tent slippage of instrument from tooth and subsequent injury to likely to be fractured. The main method of preventing adjacent tissue. A, Abras~onof Ilp as result of sliank of bur rotating on soft tlssue Wound should be kept covered wlth ant~b~ot~colntrnent B, Heallng should occur rap~dly,as observed In th~sphotograph taken 5 davs later
a healthy maxillary sinus, it is easier to nianage a displaced root than if the sinus has been chronicall!. infected. Pre~cnt~on ot Ilool ,rncl I)i\pl,~cerncntI racture If the tiisplaced tooth fra,qmcrlt is a small (2 or 3 nrm) root tip and the tooth and cinirs ha1.e no ~)recxisti~ig 1 Always plan for root fracture infection, the surgeon sho~1Ic117i;1kc a ~ninimalattempt 2 Use surg~cal(I e , open) extract~onrf hlgh probablllty at remo\,ing the root. First, a radiograph of the fractured of fracture tooth root should bc tahcn to docu~ncntits position and 3 Do not use strong ap~calforce on broken root size. Once that has I,cen ac.coml,lisheti, the surgeon should irrigate through tlic small opening in tlie socket apes and then srrction the irrigating solution from the sinns \.ia the socket. 7'hir occasionally flushes the root apex from the sinus througl~the socket. 'l'he surgeon fracture of roots is to perform ;In open e~trnc.tiontech- should check the suction solution and confirm raciio- nicluc and to remove bone to dccre;rse tlic3 amount of graphically that tlie root ha\ Iwen rcrno~mi.If this tech- force, nccei\;rr! to rcriio\.v thc tooth r l
Tooth Lost into Oropharynx !r\l)URiES TO ADIACENT TEETH Occasionally, the crown of a tooth or an entire tooth When the dentist extracts a tooth, the focus of attention might be lost down the oropharynx. If this occurs, the is on that particular tooth and the application of forces to patient should be turned toward the dentist, into a luxate and deliver it. When the surgeon's total attention mouth-down position, as much as possible. The suction is thus focused, likelihood of injury to the adjacent teeth device can then be used to help remove the tooth. The increases. The surgeon should mentally step back from patient should be encouraged to cough and spit the tooth time to time to survey the entire surgical field to prevent out onto the floor. injury to adjacent teeth. In spite of these efforts, the tooth may be swallowed or aspirated. If the patient has no coughing or respiratory Fracture of Adjacent Restoration distress, it is most likely that the tooth was swallowed and has traveled down the esophagus into the stomach. How- The most common injury to adjacent teeth is the inad- ever, if the patient has a violent episode of coughing that vertent fracture of either a restoration or a severely cari- continues, the tooth may have been aspirated beyond the ous tooth while the surgeon is attempting to luxate the larynx into the trachea. tooth to be removed with an elevator (Fig. 11-5). If a large In either case the patient should be transported to an restoration exists, the surgeon should warn the patient emergency room and chest and abdominal radiographs preoperatively about the possibility of fracturing it during taken to determine the specific location of the tooth. If the extraction. I'revention of such a fracture is primarily the tooth has been aspirated, consultation should be achieved by avoiding application of instrumentation and requested regarding the possibility of removing the tooth force on the restoration (Box 11-3).This means that the with a bronchoscope. The urgent management of aspira- straight elevator should be used with great caution or not tion is to maintain the patient's airway and breathing. used at all to luxate the tooth before extraction. If a Supplemental oxygen may be appropriate if respiratory distress appears to be occurring. If the tooth has been swallowed, it is highly probable that it will pass through the gastrointestinal (GI) tract within 2 to 4 days. Because teeth are not usually jagged or Prevention of Injury to Adjacent Teeth - - sharp, unimpeded passage occurs in almost all situations. However, it may be prudent to have the patient go to an 1. Recognize potential to fracture large restoration. emergency room and have a radiograph of the abdomen 2. Warn patient preoperatively taken to confirm the tooth's presence in the GI tract 3. Employ judicious use of ele~ instead of in the respiratory tract. Follow-up radiographs 4. Ask assistant to warn surgeGI ylc,~~reon adjacent are probably not necessary, because the usual fate of swal- teeth. lowed teeth is passage.
i- 1 . Mand~bularf~rst molar. If ~t1s to be removed, surgeon must take care not to frac- ture amalgam ~nsecond premolar wlth elevators or forceps. restoration is dislodged or fractured, the surgeon should extracted is crowded and has overlapping adjacent teeth, make sure that the displaced restoration is removed from such as is commonly seen in the mandibular incisor the mouth and does not fall into the empty tooth socket. region, thin, narrow forceps such as the no. 286 forceps, Once the surgical procedure has been completed, the may be useful for the extraction (Fig. 11-6). Forceps with injured tooth should be treated by placement of a tem- broader beaks should be avoided, because it will cause porary restoration. The patient should be informed that injury and luxation of the adjacent teeth. the fracture has occurred and that a replacement restora- If an adjacent tooth is luxated or partially avulsed, the tion must be placed (see Chapter 12). treatment goal is to reposition the tooth into its appro- Teeth in the opposite arch may also be injured as a priate position and stabilize it so that adequate healing result of uncontrolled tractional forces. This usually occurs. This usually requires that the tooth simply be occurs when buccolingual forces inadequately mobilize a repositioned in the tooth socket and left alone. tooth and excessive tractional forces are used. The tooth The occlusion should be checked to ensure that the suddenly releases from the socket, and the forceps strikes tooth has not been displaced into a hypererupted and against the teeth of the opposite arch and chips or frac- traumatic occlusion. Occasionally, the luxated tooth is tures a cusp. This is more likely to occur with extraction very mobile. If this is the case, the tooth should be stabi- of lower teeth, because these teeth may require more ver- lized with the least possible rigid fixation to maintain the tical tractional forces for their delivery, especially when tooth in its position. A simple silk suture that crosses the using the no. 23 (cowhorn) forceps. Prevention of this occlusal table and is sutured to the adjacent gingiva is type of injury can be accomplished by several methods. usually sufficient. Rigid fixation with circumdental wires First and primary, the surgeon should avoid the use of and arch bars results in increased chances for external excessive tractional forces. The tooth should be ade- root resorption and ankylosis of the tooth; therefore it quately luxated with apical, buccolingual, and rotational should usually be avoided (see Chapter 23). forces to minimize the need for tractional forces. Even when this is done, however, occasionally a tooth Extraction of Wrong Teeth releases unexpectedly. The surgeon or assistant should protect the teeth of the opposite arch by simply holding A complication that every dentist believes can never a finger or suction tip against them to absorb the blow happen-but happens surprisingly often-is extraction of should the forceps be released in that direction. If such an the wrong tooth. This should never occur if appropriate injury occurs, the tooth should be smoothed or restored attention is given to the planning and execution of the as necessary to keep the patient comfortable until a per- surgical procedure. manent restoration can be constructed. This problem may be the result of inadequate atten- tion to the preoperative assessment. If the tooth to be extracted is grossly carious, it is less likely that the wrong Luxation of Adjacent Teeth tooth will be removed. The wrong tooth is most com- Inappropriate use of the extraction instruments may lux- monly extracted when the dentist is asked to remove ate the adjacent tooth. This is prevented by judicious use teeth for orthodontic purposes, especially from patients of force with elevators and forceps. If the tooth to be who are in mixed dentition stages and whose orthodon-
'FiG. 1 i-6 A, No. 151 forceps, too wide to grasp premolar to be extracted without luxating adjacent teeth. B, Maxillary root forceps, which can be adapted easily to tooth for extraction. 228 PART 11 Prir~ci/~lccof Exotlor~tirl
Prevention of Extraction of Wrong Teeth 1 : 1. Focus attention on procedure. i 2. Enlist patient and assistant to ensure correct tooth is 1 being removed. i 3. Check, then recheck, to confirm correct tooth.
tists have asked for unusual extractions. Careful preoper- ative planning and clinical assessment of which tooth is to be removed before the forceps is applied is the main method of preventing this complication (Box 11-4). If the wrong tooth is extracted and the dentist realizes this error immediately, the tooth should be replaced immediately into the tooth socket. If the extraction is for orthodontic purposes, the dentist should contact the orthodontist immediately and discuss whether or not the tooth that was removed can substitute for the tooth that should have been removed. If the orthodontist believes the original tooth must be removed, the correct extraction d Forceps extraction of these teeth resulted ~nremoval of bone and tooth instead of just tooth. should be deferred for 4 or 5 weeks, until the fate of the replanted tooth can be assessed. If the wrongfully extract- ed tooth has regained its attachment to the alveolar process, then the originally planned extraction can pro- ceed. The surgeon should not extract the contralateral tooth until a definite alternative treatment plan is made. Prevention of Fracture of Alveolar Process If the surgeon does not recognize that the wrong tooth I 1 was extracted until the patient returns for a postoperative 1. Conduct thorough preoperative clinical and radio- visit, little can be done to correct the problem. Replanta- graphic examination. tion of the extracted tooth after it has dried cannot be 2. Do not use excessive force. successfully accomplished. 3. Use surgical (i.e., open) ext raction technique to When the wrong tooth is extracted, it is important to reduce force required. inform the patient, the patient's parents (if the patient is a minor), and any other dentist involved with the patient's care, such as the orthodontist. In some situa- tions the orthodontist may be able to adjust the treat- plate over the maxillary molars (especially the first molar), ment plan so that extraction of the wrong tooth necessi- the portions of the floor of the maxillary sinus associated tates only a minor adjustment. with maxillary molars, the maxillary tuberosity, and the labial bone on mandibular incisors (Fig. 11-7). All of these bony injuries are caused by excessive force from the forceps. INJUR1ES TO OSSEOUS STRUCTURES The primary method of preventing these fractures is to perform a careful preoperative examination of the alveo- Fracture of Alveolar Process lar process, both clinically and radiographically (Box The extraction of a tooth requires that the surrounding 11-5). Surgeons should inspect the root form of the tooth alveolar bone be expanded to allow an unimpeded path- to be removed and assess the proximity of the roots to the way for tooth removal. However, in some situations the maxillary sinus (Fig. 11-8). They should also check the bone fractures and is removed with the tooth instead of thickness of the buccal cortical plate overlying the tooth expanding. The most likely cause of fracture of the alve- to be extracted (Fig. 11-9). If the roots diverge widely, if olar process is the use of excessive force with forceps, they lie close to the sinus, or if the patient has a heavy which fractures large portions of cortical plate. If the sur- buccal cortical bone, surgeons must take special measures geon realizes that excessive force is necessary to remove a to prevent fracturing excessive portions of bone. Age is a tooth, a soft tissue flap should be elevated and controlled factor to be considered, because the bones of older amounts of bone removed so that the tooth can be easily patients are likely to be less elastic and therefore more delivered. If this principle is not adhered to and the den- likely to fracture rather than expand. tist continues to use excessive or uncontrolled force, frac- The surgeon who preoperatively determines that a ture of the bone will probably occur. high probability exists for bone fracture should consider The most likely places for bony fracture are the buccal performing the extraction by the surgical technique. cortical plate over the maxillary canine, the buccal cortical Using this method the surgeon can remove a smaller, Pre1'eiitioi7 and .Varingemeilt of S~rr~picnlComplications CHAPTER 11 229
A, Floor of slnus associated wllh roots of teeth If extraction IS requ~red, tooth should be removed surgically. B, Maxillary molar teeth lmmedlately adjacent to slnus present Increased danger of sinus exposure more controlled amount of bone, which results in more During a forceps extraction, if the appropriate amount of rapid healing and a more ideal ridge form for prosthetic tooth mobilization does not occur early, then the wise and reconstruction. prudent dentist will alter the treatment plan to the surgi- When the maxillary molar lies close to the maxillary cal technique instead of pursuing the closed method. sinus, surgical exposure of the tooth, with sectioning of Management of fractures of the alveolar bone takes sev- the tooth roots into two or three portions, will prevent eral different routes, depending on the type and severity the removal of a portion of the maxillary sinus floor. This of the fracture: If the bone has been completely removed prevents the formation of a chronic oroantral fistula, from the tooth socket along with the tooth, it should not which requires secondary procedures to close. be replaced. The surgeon should simply make sure that In summary, prevention of fractures of large portions of the soft tissue has been replaced and repositioned over the the cortical plate depends on preoperative radiographic remaining bone to prevent delayed healing. The surgeon and clinical assessment, avoidance of the use of excessive must also smooth any sharp edges that may have been amounts of uncontrolled force, and the early decision to caused by the fracture. If such sharp edges of bone exist, perform an open extraction with removal of controlled the surgeon should reflect a small amount of soft tissue amounts of bone and sectioning of multirooted teeth. and use a bone file to round off the sharp edges. 230 PART II a Prirltiplrc uf Exot/o~ltiil
Patient w~thheavy buccal cort~calplate who requlrcs open cxtractlon
-l'ht, wrgron w,ho has been supporting the alveolar fractures. The surgeon using finger support for the alveolar procc.?\ \vith the fingers during the extraction will feel the process during the fracture (if the bone remains attached to frnct~rrcof thc, I)uccal cortical plate when it occurs. At this the periosteum) should take extreme measures to ensure time thc bone rernains attached to the periosteum and the survival of that bony segment. If at all possible the \\.ill heal it it can be separated from the tooth and left bony segment should be dissected away from the tooth attached to the overlying soft tissue. The surgeon must and the tooth removed in the usual fashion. The tuberosi- carefully dissect the bone with its attached associated soft ty is then stabilized with sutures as previouslv indicated. tissue ntvay from the tooth. For this procedure the tooth However, if the tuberosity is excessively mobile and mubt be stabilized with the forceps, and a small sharp cannot be dissected from the tooth, the surgeon has sev- instrument, such as a J2roodson periosteal elevator, eral options. The first option is to splint the tooth being should I)? used to elevate the buccal bone from the tooth extracted to adjacent teeth and defer the extraction for 6 root. It is important to realize that if the soft tissue flap is to 8 weeks, during which time the bone will heal. The reflected from the bone, the blood supply to the overly- tooth is then extracted with an open surgical technique. ing bone \\.ill be severed and the bone will then undergo The second option is to section the crown of the tooth necrosis. Once the bone and soft tissue have been elevat- from the roots and allow the tuberosity and tooth root ed from the tooth, the tooth is removed and the bone section to heal. After 6 to 8 weeks the surgeon can reen- and soft tissue flap are reapproximated and secured with ter the area and remove the tooth roots in the usual fash- sutures. When treated in this fashion, it is highly proba- ion. If the maxillary molar tooth is infected, these two ble that the bone will heal in a more favorable ridge form techniques should be used with caution. for prosthetic reconstruction than if the bone had been If the maxillary tuberosity is completely separated from removed along with the tooth. Therefore it is worth the the soft tissue, the usual steps are to smooth the sharp special effort to dissect the bone from the tooth. edges of the remaining bone and to replace and suture the remaining soft tissue. The surgeon must carefully check for an oroantral communication and treat as necessary. Fracture of Maxillary Tuberosity Fractures of the maxillarv tuberositv should be viewed 1:racture of a large section of bone in the maxillary as a serious complication. The major ;herapeutic goal of tuberosity area is a situation of special concern. The max- management is to maintain the fractured bone in place illary tuberosity is especially important for the construe- and to provide the best possible environment for healing. tion of a stable retentive maxillary denture. If a large This may be a situation that can best be handled by refer- portion of this tuberosity is removed along with the max- ral to an oral and maxillofacial surgeon. illary tooth, denture stability may be compromised. The tracture of the ~nasillary tuberosity most commonly INJURIES- ---TO ADJACENT STRUCTURES results trom extraction of an erupted maxillarv third molar or from a second molar if it happens to be the last During the process of tooth extraction, it is possible to tooth in the arch (Fig. 11-10). injure adjacent tissues. The prudent surgeon preopera- If this type of fracture occurs during an extraction, tively evaluates all adjacent anatomic areas and designs a treatment is similar to that just discussed for other bony surgical procedure to prevent injury to these tissues. Prevention of Nerve Injury
1. Be aware of nerve anatomy in surgical area. 2. Avoid making incisions or affecting periosteum in j nerve area.
the area of the mental nerve and mental foramen must be performed with great care. If the mental nerve is injured, the patient will have an anesthesia or paresthesia of the lip and chin. If the injury is the result of flap reflection or simple manipulation, the altered sensation usually disap- pears in a few weeks to a few months. If the mental nerve is sectioned at its exit from the mental foramen or torn along its course, it is likely that mental nerve function will not return, and the patient will have a permanent state of anesthesia. If surgery is to be performed in the area of the mental nerve or the mental foramen, it is imperative that surgeons have a keen awareness of the potential morbidi- ty from injury to this nen7e (Box 11-6). If surgeons have any question concerning their ability to perform the indi- cated surgical procedure, they should refer the patient to an oral and maxillofacial surgeon. If a three-corner flap is to be used in the area of the mental nerve, the vertical releasing incision must be placed far enough anterior to avoid severing any portion of the mental nerve. Rarely is it advisable to make the vertical releasing incision at the interdental papilla between the canine and first premolar. 'The lingual nerve is anatomically located directly against the lingual aspect of the mandible in the retrornolar pad region. The lingual ner17e rarely regenerates if it is severely traumatized. Incisions made in the retromolar pad region of the mandible should be placed to avoid severing this nerve. Therefore incisiorls made for surgical exposure of impacted third molars or of bony areas in the posterior molar region should be made well to the buccal aspect of the mandible. <- Tuberosity rernoveti wltti iiiaxillary ,tionti iiiol
Prevention of Injury to Temporoma Joint Prevention of Oroantral Communications
1. Support mandible during extractior 1. Conduct thorouah preoperative radioara~hic d 2 4 2. Do not open mouth too widely. examini3tion. I. Use sur!gical extra ction earl:y and secilion roots. ;. Avoid e:ltcess apical pressur~e.
side may provide adequate balance of forces so that injury After the diagnosis of oroantral communication has and pain do not occur (Box 11-7). The surgeon must also been established, the surgeon must determine the approx- support the jaw as described earlier. If the patient com- imate size of the communication, because the treatment plains of pain in the TMJ immediately after the extraction will depend on the size of the opening. If the communi- procedure, the surgeon should recommend the use of cation is small (2 mm in diameter or less), no additional moist heat, rest for the jaw, a soft diet, and 1000 mg of surgical treatment is necessary. The surgeon should take aspirin every 4 hours for several days. Patients who cannot measures to ensure the formation of a high-quality blood tolerate aspirin should be given an aspirin substitute, such clot in the socket and then advise the patient to take sinus as other NSAIDs or acetaminophen. precautions to prevent dislodgment of the blood clot. Sinus precautions are aimed at preventing increases or decreases in the maxillary sinus air pressure that would OROANTRAL COMMUNICATIONS dislodge the clot. Patients should be advised to avoid Removal of maxillary molars occasionally results in com- blowing the nose, violent sneezing, sucking on straws, munication between the oral cavity and the maxillary and smoking. Patients who smoke and who cannot stop sinus. If the maxillary sinus is large, if no bone exists (even temporarily) should be advised to smoke in small between the roots of the teeth and the maxillary sinus, puffs, not in deep drags, to avoid pressure changes. and if the roots of the tooth are widely divergent, then it The surgeon must not probe through the socket into is increasingly probable that a portion of the bony floor the sinus with a periapical curette or a root tip pick. It is of the sinus will be removed with the tooth. If this com- possible that the bone of the sinus has been removed with- plication occurs, appropriate measures are necessary to out perforation of the sinus lining. To probe the socket prevent a variety of sequelae. The two sequelae of most with an instrument might unnecessarily lacerate the mem- concern are postoperative maxillary sinusitis and forma- brane. Probing of the communication may also introduce tion of a chronic oroantral fistula. The probability that foreign material, including bacteria, into the sinus and either of these two sequelae will occur is related to the thereby further complicate the situation. Probing of the size of the oroantral communication and the manage- communication is therefore absolutely contraindicated. ment of the exposure. If the opening between the mouth and sinus is of As with all complications, prevention is the easiest and moderate size (2 to 6 mm), additional measures should be most efficient method of managing the situation. Preop- taken. To help ensure the maintenance of the blood clot erative radiographs must be carefully evaluated for the in the area, a figure-of-eight suture should be placed over tooth-sinus relationship whenever maxillary molars are the tooth socket (Fig. 11-11). The patient should also be to be extracted. If the sinus floor seems to be very close to told to follow sinus precautions. Finally, the patient the tooth roots and the tooth roots are widely divergent, should be prescribed several medications to help lessen the surgeon should avoid a closed forceps extraction and the possibility that maxillary sinusitis will occur. Antibi- perform a surgical removal with sectioning of tooth roots otics, usually penicillin or clindamycin, should be pre- (see Fig. 11-8). Large amounts of force should be avoided scribed for 5 days. In addition, a decongestant nasal spray in the removal of such maxillary molars (Box 11-8). should be prescribed to shrink the nasal mucosa to keep Diagnosis of the oroantral communication can be the ostium of the sinus patent. As long as the ostium is made in several ways: The first is to examine the tooth patent and normal sinus drainage can occur, sinusitis and once it is removed. If a section of bone is adhered to the sinus infection are less likely. An oral decongestant is also root ends of the tooth, the surgeon can be relatively cer- sometimes recommended. tain that a communication between the sinus and mouth If the sinus opening is large (7 mm or larger), the den- exists. If a small amount of bone or no bone adheres to tist should consider closing the sinus communication with the molars, a communication may exist anyway. To con- a flap procedure. This usually requires that the patient be firm the presence of a communication, the best tech- referred to an oral and maxillofacial surgeon, because flap nique is to use the nose-blowing test. Pinching the nos- development and closure of a sinus opening are somewhat trils together occludes the patient's nose, and the patient complex procedures that require skill and experience. is asked to blow gently through the nose while the sur- The most commonly used flap is a buccal flap. This geon observes the area of the tooth extraction. If a com- technique mobilizes buccal soft tissue to cover the open- munication exists, there will be passage of air through the ing and provide for a primary closure. This technique tooth socket and bubbling of blood in the socket area. should be performed as soon as possible, preferably on Prevention rind Mn~zn~yemrntof Slrrgical Compliccltions a CHAPTER 11 233
Prevention of Postoperative Bleeding
1. Obtain history of bleeding. 2. Use atraurnatic surgical technique. 3. Obtain good hemostasis at surgery. 4. Provide excellent patient instructions.
FIG. 11-11 A figure-of-eight stitch is usually performed to help maintain piece of oxidized cellulose in tooth socket. As with all cbinplications, prevention of bleeding is the best way to manage this problem (Box 11-9). One of the prime factors in preventing bleeding is the taking of the same day in which the opening occurred. The same a thorough history from the patient regarding this specif- sinus precautions and medications are usually required ic potential problem. Several questions should be asked of (see Chapter 19). the patient concerning any history of bleeding. If affir- The recommendations just described hold true for mative answers to any of these questions are given, the patients who have no preexisting sinus disease. If a com- surgeon should take special efforts to control bleeding. munication does occur, it is important that the dentist The first question that patients should be asked is if they inquire specifically about a history of sinusitis and sinus have ever had a problem with bleeding in the past. The sur- infections. If the patient has a history of chronic sinus geon should inquire about bleeding after previous tooth disease, even small oroantral communications will heal extractions or previous surgery (such as a tonsillectomy) poorly and may result in permanent oroantral communi- and persistent bleeding after accidental lacerations. The sur- cation. Therefore creation of an oroantral communica- geon must listen carefully to the patient's answers to these tion in patients with chronic sinusitis is cause for referral questions, because the patient's idea of "persistent" may to an oral and maxillofacial surgeon for definitive care actually be normal. For example, it is quite normal for a (see Chapter 19). socket to ooze small amounts of blood for the first 12 to 24 The majority of oroantral communications treated in hours after extraction. However, if a patient relates a histo- the methods just recommended will heal uneventfully. ry of bleeding that persisted for more than 1 day or that Patients should be followed up carefully for several weeks required special attention from the dentist, then the sur- to ensure that this has occurred. Even patients who return geon's degree of suspicion should be substantially elevated. within a few days with a small communication usually The surgeon should inquire about any family history heal spontaneously if no maxillary sinusitis exists. These of bleeding. If anyone in the patient's family has or had patients should be followed up closely and referred to an a history of prolonged bleeding, further inquiry about its oral and maxillofacial surgeon if the communication per- cause should be pursued. Most congenital bleeding disor- sists for longer than 2 weeks. Closure of oroantral fistulae ders are familial, inherited characteristics. These congen- is important because air, water, food, and bacteria go from ital disorders vary from very mild to very profound, the the oral cavity into the sinus, often causing a chronic latter requiring substantial efforts to control. sinusitis condition. Additionally, if the patient is wearing The patient should next be asked about any medica- a full maxillary denture, suction is not as strong; therefore tions currently being taken that might interfere with retention of the denture is compromised. coagulation. Drugs such as anticoagulants may cause prolonged bleeding after extraction. Patients receiving anticancer chemotherapy or who are alcoholics may also POSTOPERATIVE BLEEDING - "" - ." tend to bleed. Extraction of teeth is a surgical procedure that presents a The patient who has a known or suspected coagulop- severe challenge to the body's hemostatic mechanism. athy should be evaluated by laboratory testing before Several reasons exist for this challenge: First, the tissues of surgery is performed to determine the severity of the dis- the mouth and jaws are highly vascular. Second, the order. It is usually advisable to enlist the aid of a hema- extraction of a tooth leaves an open wound, with both tologist if the patient has a familial coagulation disorder. soft tissue and bone open, which allows additional ooz- The means to measure the status of intentional anti- ing and bleeding. Third, it is almost impossible to apply coagulation is to use the International Normalized Ratio dressing material with enough pressure and sealing to (INR). This value takes into account both the patient's prevent additional bleeding during surgery. Fourth, prothrombin time (PT) and the control. Normal antico- patient5 tend to play with the area of surgery with their agulated status for most medical indications will have an tongues and occasionally dislodge blood clots, which ini- INR of 2.0 to 3.0. It is reasonable to perform extractions tiates secondary bleeding. The tongue may also cause sec- on patients who have an INR of 2.5 or less without reduc- ondary bleeding by creating small negative pressures that ing the anticoagulant dose. With special precautions, it is suction the blood clot from the socket. Finally, salivary reasonably safe to do minor amounts of surgery in enzymes may lyse the blood clot before it has organized patients with an INR of up to 3.0, if special local hemo- and before the ingrowth of granulation tissue. static measures are taken. 234 PART I1 Prirlciplor of E,~vtiotitirl
Primary control of bleeding during routine surgery If bleeding persists but careful inspection of the socket depends on gaining control of ali factors that may pro- reveals that it is not of an arterial origin, the surgeon long bleeding. Surgery should be as atraumatic as possi- should take additional measures to achieve hemostasis. ble, with clean incisions and gentle management of the Several different materials can be placed in the socket to soft tissue. Care should be taken not to crush the soft tis- help gain hemostasis (Fig. 11-13). The most commonly sue, because crushed tissue tends to ooze for long periods. used and the least expensive is the absorbable gelatin Sharp bony spicules should be smcothed or removed. All sponge (e.g., Gelfoam). This material is placed in the granulation tissue should be curetted from the periapical extraction socket and held in place with a figure eight region of the socket and from around the necks of adja- suture placed over the socket. The absorbable gelatin cent teeth and soft tissue flaps. This should be deferred sponge forms a scaffold for the formation of a blood clot, when anatomic restrictions, such as the sinus or inferior and the suture helps maintain the sponge in position dur- alveolar canal, are present (Fig. 11-12).The wound should ing the coagulation process. ,4 gauze pack is then placed be carefully inspected for the presence of any specific over the top of the socket and is held wit11 pressure. bleeding arteries. If such arteries exist in the soft tissue, A second material that can be used to control bleeding they should be controlled with direct pressure or, if pres- is oxidized regenerated cellulose (e.g., Surgicel). This sure fails, by clamping the artery with a hemostat and li- material promotes coagulation better than the absorbable gating it with a resorbable suture. For most oral surgical gelatin sponge, because it can be packed into the socket procedures, direct pressure over the soft tissue bleeding under pressure. The gelatin sponge becomes very friable area for 5 minutes results in complete control. when wet and cannot be packed into a bleeding socket. The surgeon should also check for bleeding from the When the cellulose is packed into the socket, it almost bone. Occasionally, a small, isolated vessel bleeds from a always causes delayed healing of the socket. Therefore bony foramen. If this occurs, the foramen can be crushed packing the socket with cellulose is reserved for more per- with the closed ends of the hemostat, thereby occluding sistent bleeding. the bleeding vessel. Once these measures have been If the surgeon has special concerns about the patient's accomplished, the bleeding socket is covered with a ability to clot, a liquid preparation of topical thrombin damp gauze sponge that has been folded to fit directly (prepared from bovine thrombin) can be saturated onto a into the area from which the tooth was extracted. The gelatin sponge and inserted into the tooth socket. The patient bites down firmly on this gauze for at least 30 thrombin bypasses all steps in the coagulation cascade minutes. The surgeon should not dismiss the patient and helps to convert fibrinogen to fibrin enzymatically, from the office until hemostasis has been achieved. This which forms a clot. The sponge with the topical thrombin recluires that the surgeon check the patient's extraction is secured in place with a figure-eight suture. A gauze pack socket about 15 minutes after the completion of surgery. is placed over the extraction site in the usual fashion. The patient should open the mouth widely, the gauze A final material that can be used to help control a should be removed, and the area should be inspected bleeding socket is collagen. Collagen promotes platelet carefully for any persistent oozing. Initial control should aggregation and thereby helps accelerate blood coagula- have been achieved. New damp gauze is then folded and tion. Collagen is currently available in several different placed into position, and the patient is told to leave it in forms. Microfibular collagen (e.g., Avitene) is available as place for an additional 30 minutes. a fibular material that is loose and fluffy but can be
Crarlulorna of second premolar Surgeon should not curettp per~ap~callyaround th~ssecond premolar to remove granuloma because rtsk for slnus perforation IS h~gh. Preveiltioil niltl ,Mtri~ngeriroiltof Srrr;yitrrl Coii~/~lic.ntioir.s@ CHAPTER 11 235 packed into a tooth socket and held in by suturing and generalized oozing, the bleeding site is covered with a gauze packs, as with the other materials. A more highly folded, damp gauze sponge held in place with firm pres- cross-linked collagen is supplied as a plug (e.g., Collaplug) sure by the surgeon's finger for at least 5 minutes. or as a tape (e.g., Collatape). These materials are more readily packed into a socket (Fig. 11-14) and are easier to use. They are also more expensive. Even after primary hemostasis has been achieved, patients occasionally call the dentist with bleeding from the extraction site, referred to as secondary bleeding. The patient should be told to rinse the mouth gently with very cold water, then place appropriate-sized gauze over the area and bite firmly. The patient should sit quietly for 30 min- utes, biting firmly on the gauze. If the bleeding persists, the patient should repeat the cold rinse and bite down on a damp tea bag. The tannin in the tea will frequently help stop the bleeding. If neither of these techniques is success- fill, the patient should return to the dentist. The surgeon must have an orderly, planned regimen to control this secondary bleeding. The patient should be positioned in the dental chair, and all blood, saliva, and fluids should be suctioned from the mouth. Such patients will frequently have large "liver clots" in their mouth, Flf t Mater~al that can be used In a bleed~rig socket which must be removed. The surgeon should visualize Clockw~sefrom the canlne tooth: collagen plug, m~crof~bularcolla- the bleeding site carefully with good light to determine gen, regenerated oxldlzed cellulose, collagen tape, and absorbable the precise source of bleeding. If it is clearly seen to be a gelat~nsponge
A, Collagen shaped Into the form of a plug IS s~m~larIn slze to the root of a rnax~llary canlne. B and C, The collagen plug IS placed ~ntothe socket wlth cotton pl~ers(arrow) D, A f~gure- e~ghtsuture 1s placed over the socket to ma~nta~nthe collagen In the socket. 236 PART I1 8 Priticiples of Exorfotltin
This measure is sufficient to control most bleeding. removal. Careful asepsis and thorough wound debride- The reason for the bleeding is usually some secondary ment after surgery can best achieve prevention of infec- trauma that is potentiated by the patient's continuing to tion after surgical flap procedures. This means that the suck on the area or to spit blood from the mouth instead area of bone removal under the flap must be copiously of continuing to apply pressure with a gauze sponge. irrigated with saline and that all foreign debris must be If 5 minutes of this treatment does not control the removed with a curette. Some patients are predisposed to bleeding, the surgeon must administer a local anesthetic postoperative wound infections and should be given peri- so that the socket can be treated more aggressively. Block operative prophylactic antibiotics (see Chapter 15). techniques are to be encouraged instead of local infiltra- tion techniques. Infiltration with solutions containing epinephrine cause vasoconstriction and may control the Wound Dehiscence bleeding temporarily. However, when the effects of the Another problem of delayed healing is wound dehiscence epinephrine dissipate, rebound hemorrhage with recur- (Box 11-10). If a soft tissue flap is replaced and sutured rent bothersome bleeding may occur. without an adequate bony foundation, the unsupported Once local anesthesia has been achieved, the surgeon soft tissue flap often sags and separates along the line of should gently curette out the tooth extraction socket and incision. A second cause of dehiscence is suturing the suction all areas of old blood clot. The specific area of wound under tension. If the soft tissue flap is sutured bleeding should be identified as clearly as possible. As under tension, the sutures cause ischemia of the flap mar- with primary bleeding, the soft tissue should be checked gin with subsequent tissue necrosis, which allows the for diffuse oozing versus specific artery bleeding. The suture to pull through the flap margin and results in bone tissue should be checked for small nutrient artery wound dehiscence. Therefore sutures should always be bleeding or general oozing. The same measures described placed in tissue without tension and tied loosely enough for control of primary bleeding should be used. The sur- to prevent blanching of the tissue. geon must then decide if a hemostatic agent should be A common area of exposed bone after tooth extraction inserted into the bony socket. The use of an absorbable is the internal oblique ridge. After extraction of the first gelatin sponge with topical thrombin held in position and second molar, during the initial healing, the lingual with a figure-of-eight stitch and reinforced with applica- flap becomes stretched over the internal oblique (mylo- tion of firm pressure from a small, damp gauze pack is hyoid) ridge. Occasionally, the bone will perforate standard for local control of secondary bleeding. This through the thin mucosa, causing a sharp projection of technique works well in almost every bleeding socket. In bone in the area. many situations an absorbable gelatin sponge and gauze The two major treatment options are (1) to leave the pressure are adequate. The patient should be given spe- projection alone, or (2) to smooth it with bone file. If the cific instructions on how to apply the gauze packs direct- area is left to heal untreated, the exposed bone will ly to the bleeding site should additional bleeding occur. slough off in 2 to 4 weeks. If the irritation of the sharp Before the patient with secondary bleeding is discharged bone is low, this is the preferred method. If a bone file is from the office, the surgeon should monitor the patient used, no flap should be elevated, because this will result for at least 30 minutes to ensure that adequate hemosta- in an increased amount of exposed bone. The file is used tic control has been achieved. only to smooth off the sharp projections of the bone. If hemostasis is not achieved by any of the local meas- This procedure usually requires local anesthesia. Patients ures just discussed, the surgeon should consider perform- who are quite annoyed by the sharp bone will usually ing additional laboratory screening tests to determine if choose this method. the patient has a profound hemostatic defect. The dentist usually requests a consultation from a hematologist, who Dry Socket orders the typical screening tests. Abnormal test results will prompt the hematologist to investigate the patient's Dry socket or alveolar osteitis is delayed healing but is not hemostatic system further. associated with an infection. This postoperative complica- A final hemostatic complication relates to intraopera- tion causes moderate-to-severe pain but is without the tive and postoperative bleeding into the adjacent soft usual signs and symptoms of infection, such as fever, tissues. Blood that escapes into tissue spaces, especially swelling, and erythema. The term dry socket describes the subcutaneous tissue spaces, appears as bruising of the appearance of the tooth extraction socket when the pain overlying soft tissue 2 to 5 days after the surgery. This bruising is termed eccl~ytnosis(see Chapter 10).
DELAYED HEALING AND INFECTION Prevention of Wound Dehiscence
Infection 1. Use aseptic technique. The most common cause of delayed wound healing is 2. Perform atraumatic surgery. infection. Infection is a rare complication after routine 3. Close incision over intact bone. dental extraction and is primarily seen after oral surgery 4. Suture without tension. that involves the reflection of soft tissue flaps and bone Prevention and Management of Surgical Complications CHAPTER 11 237 begins. In the usual clinical course, pain develops on the with saline at each dressing change. Once the patient's third or fourth day after removal of the tooth. On exami- pain decreases, the dressing should not be replaced, nation the tooth socket appears to be empty, with a par- because it acts as a foreign body and further prolongs tially or completely lost blood clot, and the bony surfaces wound healing. of the socket are exposed. The exposed bone is extremely sensitive and is the source of the pain. The dull, aching pain is moderate to severe, usually throbs, and frequently FRACTURES- - OF - THE MANDIBLE "------radiates to the patient's ear. The area of the socket has a bad Fracture of the mandible during extraction is a rare com- odor, and the patient frequently complains of a bad taste. plication; it is associated almost exclusively with the sur- The cause of alveolar osteitis is not absolutely clear, gical removal of impacted third molars. A mandibular but it appears to be the result of high levels of fibrinolyt- fracture is usually the result of the application of a force ic activity in and around the tooth extraction socket. This exceeding that needed to remove a tooth and often fibrinolytic activity results in lysis of the blood clot and occurs during the use of dental elevators. However, when subsequent exposure of the bone. The fibrinolytic activi- lower third molars are deeply impacted, even small ty may be the result of subclinical infections, inflamma- amounts of force may cause a fracture. Fractures may also tion of the marrow space of the bone, or other factors. occur during removal of impacted teeth from a severely The occurrence of a dry socket after a routine tooth atrophic mandible. Should such a fracture occur, it must extraction is relatively rare (2% of extractions), but it is be treated by the usual methods used for jaw fractures. quite frequent after the removal of impacted mandibular The fracture nus st be adequately reduced and stabilized third molars (20% of extractions). with intermaxillary fixation. Usually this means that the Prevention of the dry socket syndrome requires that patient should be referred to an oral and maxillofacial the surgeon minimize trauma and bacterial contamina- surgeon for definitive care. tion in the area of surgery. The surgeon should perform atraumatic surgery with clean incisions and soft tissue reflection. After the surgical procedure, the wound SUMMARY ------should be thoroughly debrided and irrigated with large Prevention of complications should be a major goal of quantities of saline. Small amounts of antibiotics (e.g., the surgeon. Skillful management of complications when tetracycline) placed in the socket alone or on a gelatin they do occur is the sine qua non of the wise and mature sponge may help to decrease the incidence of dry socket surgeon. in mandibular third molars. The incidence of dry socket The surgeon who anticipates a high probability of an can also be decreased by preoperative and postoperative unusual specific complication should inform the patient rinses with antimicrobial mouth rinses, such as chlorhex- and explain the anticipated management and sequelae. idine. Well-controlled studies indicate that the incidence Notation of this should be made in the informed consent of dry socket after impacted mandibular third molar sur- that the patient signs. gery can be reduced by up to 50%. The treatment of alveolar osteitis is dictated by the single therapeutic goal of relieving the patient's pain dur- ing the period of healing. If the patient receives no treat- BlBtlOCRAPHY - - - "" *------ment, no sequela other than continued pain exists (treat- Birn H: Etiology and pathogenesis of fibrinolytic alveolitis, Int J ment does not hasten healing). Oral Sur~2:211, 1973. Treatment is straightforward and consists of gentle Hall HD, Bildman BS, Hand CD: Prevention of dry socket with irrigation and insertion of a medicated dressing. First, the local application of tetracycline, Oral Surg 29:35, 1971. tooth socket is gentlv irrigated with saline. The socket Kohn MW, Chase DC, Marciani RD: Surgical misadventures, Dent ", - ' should not be curetted down to bare bone, because this Clin North Am 17533, 1973. increases both the amount of exposed bone and the pain. Larsen PE: The effect of chlorhexidine rinse on the incidence of Usually the entire blood clot is not lysed, and the part alveolar osteitis following the surgical removal of impacted mandibular third molars, J Oral Maxillofac Surg 49:932, 1991. that is intact should be retained. The socket is carefully Moake JL: Common bleeding problems, Cibn Symp suctioned of all excess saline, and a small strip of iodo- 35(3):1, 1983. form gauze soaked with the medication is inserted into Ngeow WC: Management of the fractured maxillary tuberosity: the socket. The medication contains the following prin- an alternative method, Qzrintessence Int 29:189, 1998. cipal ingredients: eugenol, which obtunds the pain from Osbon DR: Postoperative complications following dentoalveolar the bone tissue; a topical anesthetic, such as benzocaine; surgery, Dent CIin North Am 17:483, 1973. and a carrying vehicle, such as balsam of Peru. The med- Redding SW, Stiegler KE: Dental management of the classic ication can be made by the surgeon's pharmacist or can hemophiliac with inhibitors, Oral Surg 56:145, 1983. be obtained as a commercial preparation from dental sup- Steinberg MJ, Moores JF: Use of INR to assess degree of anticoag- ulation in patients who have dental procedures, Oral Surg ply houses. Om1 Med Oral Path01 Oral Radio1 Enriod 80: 175, 1995. The is the socketf medicated gauze gently inserted Sweet JB, Butter DP, Drager JL: Effects of lavage techniques with and the patient usually experiences profound relief from third molar surgery, Oral Surg 41:152, 1976. pain within 5 minutes. The dressing is changed every day Troulis MJ, Head TW, Lederc JC: What is the INR? J Can Dent or every other day for the next 3 to 6 days, depending on Assoc 62(suppl):428, 1996. the severity of the pain. The socket is gently irrigated Waite DE: Maxillary sinus, Dent Clin North Am 15:349, 1971.