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Table of Contents   
ORIGINAL RESEARCH  
Year : 2011  |  Volume : 22  |  Issue : 5  |  Page : 633-638
Complications of exodontia: A retrospective study


Department of Oral and Maxillofacial Surgery, Padmashree Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil University, Nerul, Navi Mumbai, India

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Date of Submission20-Oct-2010
Date of Decision30-Dec-2010
Date of Acceptance03-Jul-2011
Date of Web Publication7-Mar-2012
 

   Abstract 

Purpose: The purpose of this study was to analyze the incidence of various complications following routine exodontia performed using fixed protocols.
Materials and Methods: A total of 22,330 extractions carried out in 14,975 patients, aged between 14 and 82 years, who reported to the Department of Oral and Maxillofacial Surgery at Padmashree Dr. D. Y. Patil Dental College and Hospital, Nerul, Navi Mumbai, were evaluated for various complications.
Results: The most common complications encountered were tooth fracture, trismus, fracture of cortical plates and dry socket. Wound dehiscence, postoperative pain and hemorrhage were encountered less frequently. Luxation of adjacent teeth, fracture of maxillary tuberosity, and displacement of tooth into adjacent tissue spaces were rare complications.
Conclusion: The practice of exodontia inevitably results in complications from time to time. It is imperative for the clinician to recognize impending complications and manage them accordingly.

Keywords: Complications, dry socket, exodontia, tooth displacement

How to cite this article:
Venkateshwar GP, Padhye MN, Khosla AR, Kakkar ST. Complications of exodontia: A retrospective study. Indian J Dent Res 2011;22:633-8

How to cite this URL:
Venkateshwar GP, Padhye MN, Khosla AR, Kakkar ST. Complications of exodontia: A retrospective study. Indian J Dent Res [serial online] 2011 [cited 2014 Jul 26];22:633-8. Available from: http://www.ijdr.in/text.asp?2011/22/5/633/93447
Exodontia is the most common surgical procedure performed in the speciality of Oral and Maxillofacial Surgery.

Complications are unforeseen events that tend to increase the morbidity, above what would be expected from a particular operative procedure under normal circumstances. [1] Though they are rare, their occurrence leads to a prolonged phase of treatment, which is cumbersome to the patient as well as the clinician.

The dictum that to prevent a complication from occurring is the best way to manage one remains time tested. Thus, it becomes imperative that the clinician is aware and recognizes the whole spectrum of complications and their implications.

Complications can be wide, ranging from common ones like dry socket and root fracture to uncommon and serious ones like displacement of a root fragment in the maxillary sinus and oro-antral fistula [Table 1].
Table 1: Articles showing incidence of complications of simple tooth extraction

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Careful attention to details including a thorough case history, routine investigations like radiographs and blood investigations is an inherent part of exodontia. Adjunctive investigations like a Cone Beam Computed Tomography (CBCT) scan can be performed to assess the difficulty of a case. These investigations can pre-warn a clinician about any impending complication.

The purpose of this study was to analyze the incidence and distribution of complications following routine extractions performed in the Department of Oral and Maxillofacial Surgery at Padmashree Dr. D. Y. Patil Dental College and Hospital, Nerul, Navi Mumbai.


   Materials and Methods Top


A retrospective study of 22,330 extractions carried out in 14,975 patients who reported to the Department of Oral and Maxillofacial Surgery at Padmashree Dr. D. Y. Patil Dental College and Hospital was conducted.

The study included 8464 males and 6511 females, with age ranging from 14 to 82 years with a mean age of 41 years.

Only healthy individuals were included in the study. Medically compromised patients, pregnant and lactating mothers were excluded from this study.

Only simple extractions requiring simple elevation and forceps application were included in the study. More complex extractions requiring reflection of soft tissue flaps and surgical bone removal for extraction of the teeth were excluded from the study.

The causes for the extraction of teeth have been enumerated in [Table 2]. The anatomic distribution of the extracted teeth has been shown in [Table 3].
Table 2: Cause for extraction of tooth

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Table 3: Anatomic distribution of teeth extracted

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In all cases, 2% lignocaine hydrochloride with 1:80,000 adrenalin solution was used to provide anesthesia.

Local infiltration, infraorbital nerve block, posterior superior alveolar nerve block or inferior alveolar nerve block were used depending upon the anatomic distribution of the teeth to be extracted.

A maximum of 5 ml of local anesthetic solution was injected in each patient.

All patients in the study group were prescribed antibiotics and analgesics and explained about wound care postoperatively.

Postoperatively; all patients were prescribed antibiotics, i.e. amoxycillin (250/500 mg) or a combination of amoxycillin (250 mg) + cloxacillin (250 mg), depending on the severity of the infection.

All patients were prescribed antibiotics postoperatively as all the extractions were performed by undergraduates and interns, resulting in longer, more traumatic extractions, increasing the risk of secondary infection or an acute exacerbation of existing infection. Also, as caries and periodontitis were the major causes for tooth extraction, the patients presented with pre-existing infection that needed to be controlled.

Patients were asked to resume oral hygiene habits (tooth brushing two times per day) 24 hours postoperatively.

Tobacco smoking history was not included in this study.

In cases where suturing was required, 3-0 silk was used to achieve closure.

The cases were distributed randomly to the operators.

The extractions carried out were evaluated for the following complications:

  • Fractured tooth
  • Laceration
  • Soft tissue injury
  • Luxation of adjacent tooth/teeth
  • Fracture of cortical plates
  • Fracture of maxillary tuberosity
  • Fracture mandible
  • Hemorrhage
  • Displacement of tooth/root in the maxillary antrum
  • Displacement of tooth/root into adjacent tissue space
  • Dry socket
  • Trismus
  • Postoperative pain
  • Infection
  • Wound dehiscence
Fractured tooth included crown and/or root fracture.

Hemorrhage included only primary hemorrhage.

Cortical plates included both buccal (labial) and lingual (palatal) plates.

Dry socket was defined as postoperative pain inside and around the extraction site, which increased in severity at any time between the first and third day after the extraction, accompanied by a partial or total disintegrated blood clot, with or without halitosis.

Healing was assessed by clinical examination of the patient, as well as patient feedback regarding pain, halitosis, dysgeusia, etc.


   Results Top


Between October 2007 and September 2010, 23,242 extractions were carried out in 15,817 patients in the Department of Oral and Maxillofacial Surgery [Figure 1].
Figure 1: Total no. of patients from October 2007 to September 2010

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Extractions in medically compromised/pregnant/lactating patients = 912 extractions in 842 patients.

Sample size = 22,330 extractions in I4,975 healthy patients [Figure 2].
Figure 2: Excluded and included patients

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Complications

The complications noted are given in [Table 4],[Table 5],[Table 6] and [Table 7] and [Figure 3],[Figure 4],[Figure 5],[Figure 6] and [Figure 7].
Figure 3: Bar graphs showing a comparison of the complications occuring with a high frequency

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Figure 4: Donut chart showing a comparison of complications occuring with a high frequency

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Figure 5: Pie chart showing a comparison of complications occurring with a medium frequency

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Figure 6: Pie chart showing a comparison of complications occurring with a low frequency

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Figure 7: Conical graph showing a comparison of complications occurring with a low frequency

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Table 4: Incidence of the complications

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Table 5: Distribution of the complications between interns and undergraduates

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Table 6: Relation between time taken for the procedure and number of complications

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Table 7: Incidence of complications in maxilla and mandible

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Thus, in this study, it is seen that the major causes of extraction were caries and periodontitis, followed by orthodontic purposes, trauma and endodontic failure.

The largest number of extractions was carried out in the mandibular posterior segments, followed by the maxillary posterior segments, the maxillary anteriors and finally the mandibular anteriors.

Also, it was observed that the fracture of tooth is the most common complication, followed by trismus, fracture of cortical plates and dry socket. Wound dehiscence, postoperative pain and hemorrhage showed a medium incidence. Luxation of adjacent teeth, displacement of tooth into maxillary antrum/adjacent tissue spaces, infection and fracture of maxillary tuberosity were comparatively rare complications.

No cases of fracture mandible were recorded.

A higher incidence of complications was seen when undergraduates carried out the extractions, compared to the interns; when the operative time exceeded 30 minutes as compared to procedures completed within 30 minutes; and when the extractions were carried out in the mandibular arch as compared to the maxillary arch.


   Discussion Top


Although careful attention to surgical details, including proper patient preparation, asepsis, and meticulous management of hard and soft tissue, controlled force when applying surgical instruments, hemostasis and adequate postoperative instructions, may help to reduce the rate of complications, it has not been found to eliminate them.

The factors that contribute to such complications are numerous and include the patient or may be tooth related, and also include the surgeon's operative experience. [2],[3] Other factors found to affect the complication rate include age [4] and gender [5] of the patient.

This study shows a higher incidence of tooth fracture (20.4%), trismus (18%), fracture of cortical plates (16.2%) and dry socket (11.7%).

It was seen that in majority of the cases of fracture of cortical plates, it was the buccal plate that was fractured, while the lingual and palatal cortical plates were fractured only in a few instances.

The incidence of dry socket for routine dental extractions has been reported to be in the range of 5-20%, [6],[7],[8],[9] while its incidence after extractions of third molar varies from 1 to 37.5%. [10],[11] Increased occurrence is seen in smokers [12],[13],[14] and patients on oral contraceptives. [15],[16],[17]

Trismus is an objective finding, and thus difficult to measure objectively despite being readily observable. [18]

Postoperative pain (3.9%), wound dehiscence (3.5%) and hemorrhage (1.3%) were the less frequent complications.

A 100-mm visual analogue scale (VAS) was used for the assessment of postoperative pain, [19] 2 days and 7 days postoperatively. The patients described the character of pain as constant, shooting, or dull while chewing. The assessment was done within 15 min of administration of the pain medication.

Fracture of maxillary tuberosity (0.5%), infection (0.4%), fracture mandible, luxation of adjacent tooth (0.13%), displacement of tooth into adjacent tissue spaces (0.05%) and displacement of tooth into maxillary sinus (0.04%) were some of the rarer complications.

The maxillary tuberosity is an important retentive area for maxillary complete dentures and every effort must be made to preserve it.

The accidental displacement of teeth into fascial spaces constitutes an unusual complication. However, there are reports in the literature of displacement of teeth into the infratemporal fossa, [20] maxillary sinus, [21] submandibular space, [22] pterygomandibular space, [23] lateral pharyngeal space, [24] and lateral cervical region. [25]

A higher incidence of complications was probably seen as the operators were the lesser experienced undergraduates and interns. Also, a higher incidence of complications was seen when extractions were carried out by undergraduates (63%), as compared to interns (37%).

The amount of time required to complete the procedure was also a contributing factor, as a higher incidence of complications was seen in the procedures requiring 30-60 min for completion (65%), as compared to the procedures that were completed within 30 min (35%).

Also, a higher incidence of complications was seen in extractions carried out in the mandible (55%), as compared to the maxilla (45%). This could be attributed to the fact that trismus and dry socket, which made up a major chunk of the complications, occurred in the mandible.


   Conclusion Top


The practice of exodontia inevitably results in complications from time to time. These complications range from simple ones like dry socket to ones like displacement of a tooth in the maxillary sinus.

The clinician must possess the clinical acumen to recognize impending complications and manage them accordingly.

Following the axiom "prevention is better than cure" [26] still remains the best way to manage any complication.

Undergraduate includes third and final year students

Null hypothesis

There is an association between column and row attributes

Interpretations

Since P-value is very small and less than 0.05, we reject null hypothesis of no association and conclude that there is relationship between column and row attributes, i.e. operator experience, time taken for the procedure, arch in which the procedure is performed and number of extractions and number of complications

Null hypothesis

There is an association between column and row attributes

Interpretations

Since P-value is very small and less than 0.05, we reject null hypothesis of no association and conclude that there is relationship between column and row attributes, i.e. operator experience, time taken for the procedure, arch in which the procedure is performed and number of extractions and number of complications

Null hypothesis

There is an association between column and row attributes

Interpretations

Since P-value is very small and less than 0.05, we reject null hypothesis of no association and conclude that there is relationship between column and row attributes, i.e. operator experience, time taken for the procedure, arch in which the procedure is performed and number of extractions and number of complications

 
   References Top

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2.Shepherd JP, Brickley M. Activity analysis: Measurement of the effectiveness of surgical training and operative technique. Ann R Coll Surg Engl 1992;74:417-20.  Back to cited text no. 2
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3.Sisk AL, Hammer WB, Shelton DW, Joy ED Jr. Complications following extractions of third molars: The role of experience of the surgeon. J Oral Maxillofac Surg 1986;44:855-9.  Back to cited text no. 3
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4.Bruce RA, Fredricson GC, Small GS. Age of the patients and morbidity associated with mandibular third molar surgery. J Am Dent Assoc 1980;101:240-5.  Back to cited text no. 4
    
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11.Swanson AE. Reducing the incidence of dry socket: A clinical appraisal. J Can Dent Assoc 1966;32:25-33.  Back to cited text no. 11
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13.Sweet JB, Butler DP. Predisposing and operative factors: Effect on the incidence of localised osteitis in mandibular third molar surgery. Oral Surg Oral Med Oral Pathol 1978;46:206-15.  Back to cited text no. 13
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14.Nusair YM, Abu Younis MH. Prevalence, clinical picture and risk factors of dry socket in a Jordanian dental teaching center. J Contemp Dent Pract 2007;8:53-63.  Back to cited text no. 14
    
15.Cohen ME, Simicek JW. Effect of gender related factors on the incidence of localised alveolar osteitis. Oral Pathol Oral Radiol Endodontol 1995;79:416-22.  Back to cited text no. 15
    
16.Hermesch CB, Hilton TJ, Biesbrock AR. Peri-operative use of 0.12% chlorhexidene gluconate for the prevention of alveolar osteitis: Efficacy and risk factor analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 1998;85:381-7.  Back to cited text no. 16
    
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18.Norholt SE, Aagard E, Svensson P, Sindet Pederson S. Evaluation of trismus, bite force, and pressure algometry after third molar surgery: A placebo controlled study of ibuprofen. J Oral Maxillofac Surg1998;56:420-7.  Back to cited text no. 18
    
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20.Gulbrandsen SR, Jackson IT, Turlington EG. Recovery of a maxillary third molar from the infratemporal space via a hemicoronal approach. J Oral Maxillofac Surg 1987;45:279.  Back to cited text no. 20
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21.Peterson LJ, Ellis E 3 rd , Hupp JR. Contemporary Oral and Maxillofacial Surgery. 3 rd ed. St. Louis: Mosby; 1998.  Back to cited text no. 21
    
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24.Ertas U, Yaruz MS, Tozuglu S. Accidental third molar displacement into the lateral pharyngeal space. J Oral Maxillofac Surg 2002;60:1217.  Back to cited text no. 24
    
25.Gay-Escoda C, Berini-Aytez L, Pinera-Penalva M. Accidental displacement of an impacted mandibular third molar: Report of a case in the lateral cervical position. Oral Surg Oral Med Oral Pathol 1993;76:159.  Back to cited text no. 25
    
26.Booth PW, Schendel SA, Worrall SF. Maxillofacial Surgery. 2 nd ed. Philadelphia: Churchill Livingstone; 2007.  Back to cited text no. 26
    

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Correspondence Address:
Aman Rajiv Khosla
Department of Oral and Maxillofacial Surgery, Padmashree Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil University, Nerul, Navi Mumbai
India
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DOI: 10.4103/0970-9290.93447

PMID: 22406704

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    Figures

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