Download Oral Surgery - Post-op Management of Complications

Oral Surgery
Post Surgical
Considerations
Dr. Michael J. Strohecker DMD
Postoperative Bleeding
• Gauze Pack
• Direct Pressure
– Often overlooked, but very effective
• Unravel 2X2 gauze, stuff into exo site using Dubakie Forceps
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or cotton pliers, keep direct pressure on gauze for 5 minutes.
Repeat if needed
• Clotting Agent
– Surgicel
– Gel-Foam
Ecchymosis and Edema
Who’s at Risk?
• Ecchymosis
– Bruise in the oral tissue of the face
– Caused by blood in subcutaneous tissue
– Often seen in older patients due to decreased tissue
tone and weaker intercellular attachment.
– Often appears the next day
– Looks scary but isn’t
– Self limiting / Self resolving
– Inform patient in advance
Edema
Who’s at Risk?
• Occurs with most surgical extractions when a
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mucoperiosteal flap is used.
Reaches maximum in 48 – 72 hrs
If swelling continues to increase may be due to
infection
Ice Pack first 24 hours
Warm moist compresses second 24 hours
Inform patient in advance that swelling will
occur
Trismus
Now what do I do?
• Limited post-surgical occlusal opening due to
inflammation of muscles of mastication
• Self Limiting
• Inform patient in advance
• Possible Causes
– Injection of anesthetic most often into medial pterygoid
– Complicated surgical procedure requiring full thickness
mucoperiosteal flaps and osteotomy such as third molar
exodontia
Lock Jaw
Now what do I do?
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First yell “Dag Gum It!”
Condyle slips past Articular Eminence /disc
May occur if patients over articulate
Patients usually know, so ask in advance
Patients are often able to reposition TMJ themselves
If help is needed
– Multiple tongue blade’s over posterior occlusal surfaces of
mandible
– Downward pressure, ease mandible inferiorly and posteriorly
– May snap back into place…keep thumbs clear
Post-Op Pain
• #1 Alveolar Osteitis / Dry Socket
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Describes appearance of socket
Not associated with infection (?)
Usually appears 3 – 4 days post-op
Best way to avoid:
• Good Surgical Technique / minimally invasive
• Debride all granulation tissue after extraction if possible
• Irrigate w/ distilled / sterile water
• Most commonly associated with tobacco smokers (90%)
Alveolar Osteitis
• Treatment
– Systemic Analgesics
– Topical Analgesics
• Debride area of poor clot via Chlorohexadine
• Place Dry Socket Dressing
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Sultan Paste on Gel-Foam
Sultan Paste on Iodoform Gauze
Canfield Dressing
Do not keep in place for longer than 72 hours
Repeat if needed
– Combination of Both
Post-Op Pain
• Subperiostial Space Infection
• Antibiotics usually ineffective
– Mandibular Swelling where mucoperiostial flap
surgery was performed
– Initial healing appears to be WNL
– Usually appears two weeks post – surgery
– Often caused by foreign body or invasion of infectious
organism between bone and periostium
– Requires exploratory surgery
• Access, curettage / debride, irrigate, reapproximate
Soft Tissue Injury
During Oral Surgery
• Mucoperiosteal Flap tears or is perforated in an
undesired area
• Causes
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Thin / friable tissue
Poor surgical technique
Patient moves
Treatment
- Inform Patient
- Reapproximate and suture
- “Time Heals all Wounds”
Injury to Osseous Structures
• Fractured or removed Tuberosity
– “If you haven’t fractured a tuberosity then
you haven’t taken out enough teeth!”
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CAPT H. J. Willoughby OMFS
Injury to Osseous Structures
• Fractured or removed Tuberosity
• Can splint tooth and retry in 6-8 weeks using surgical
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technique
Can remove crown w/ handpiece, (may need
pulpectomy) allow to heal 6-8 weeks then remove
retained roots using surgical technique
Proper Pre-surgical planning
– “When in doubt, send it out!”
• Good surgical technique
– Section tooth
– Distal osteotomy
Oroantral Communication
AKA: Sinus Exposure
• Often Associated with extraction of Maxillary third Molars
• “BEWARE OF THE LONE MOLAR!!!”
• Careful Case Selection
– Does the patient have a thin Antrum? Usually assoc w/ older
patients
– Divergent roots?
– Deep Radicular Sinus Penetration?
– If you decided to extract…
• Avoid closed forcep extraction
• Section tooth
– Laterally engage root segments avoiding superior force that would
displace these segments into sinus.
– “When in doubt…..send it out!”
Oroantral Communication
AKA: Sinus Exposure
• If an Oroantral Communication is suspected
– Test w/ Valsalva Technique
– If >2mm no surgical tx is needed / avoid sinus pressure (No
nose blowing, sneeze w/ open mouth, do not smoke / suck
through straw)
– If <2mm then primary closure is required
• May be achieved using clotting agent such as Gel- Foam sutured
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into place w/ figure eight stitch
Sliding Flap techniques / Gortex or foil membrane (>7mm)
Systemic coverage:
– Antibiotics such as Augmentin, Penicillin, Erythromycin
– OTC decongestants
– Afrin nose spray may be considered
“When in doubt…send it out!”
Fracture of Mandible
Know your limits!
• Careful case selection
• Careful Surgical Technique
– Avoid considerable lateral forces if using forceps
– Consider surgical extraction
• Considerations:
– Inferior Border of Mandible is thin
– Tooth takes up large volume of mandibular structure
as in impacted third molar's
Questions?
Thanks!