Cheek Tooth Exodontia Complications

Take Home Message—To date, oral extraction of cheek teeth is recognized as the method for exodontia with the lowest complication rate. However, minor or major complications during all phases of the process including the convalescing period might occur.

I. Aim of the presentation

To list potential complications during and after oral cheek tooth extraction and make suggestions for prevention or management of complications.

II. Introduction

Although oral extraction of cheek teeth is the preferred technique for exodontias,^1-4 minor and major complications might occur at all stages of the procedure and in the convalescing period.^1-5 In this presentation the most common reasons for complications and some problems with low incidence are discussed. Suggestions for prevention and management of the respective complications are made.

III. Material and methods

A list of potential problems before (4.1) during (4.2) and in the course of the period after cheek tooth extraction (4.3) is presented. Suggestions for prevention or management of the problems are given.

4.1. Complications prior to extraction

4.1.1. Complications with sedation

Not discussed in this abstract.

4.1.2. Complications with local anesthesia (see in Proceedings: Local Anesthesia for Dental Procedures, Simhofer)

4.1.3. Complications in association with flushing of the oral cavity

• Aspiration of water/blood
  Suggestion: The head should always be lowered when the oral cavity is flushed. The mouth should be flushed frequently when bleeding occurs. If the horse is bleeding severely hemostasis should be accomplished before continuing with the extraction. If aspiration of blood might have occurred, an endoscopic examination of the upper airways should be performed and broad spectrum antibiotics should be administered to prevent pneumonia. The horse should be closely monitored in the postoperative days for pathological respiratory symptoms.

4.1.4. Complications with the speculum

• Reluctance to open the mouth
  Opening of the oral cavity should never be forced.
  Suggestions: Rule out mandibular/maxillary fracture(s)6 and pathologic conditions of the temporomandibular joint (TMJ).
   
• Maxillary/mandibular fracture caused by mouth opening with a speculum
  Suggestion: X-rays are recommended in geriatric patients and suspected pathological conditions of the facial bones prior to insertion of a full mouth speculum.
   
• Speculum breaks
  Although never personally encountered, the author is aware of one anecdotal case.
  Suggestion: If no trauma had been inflicted to the animal, the veterinarian or assistants, the speculum can be replaced and the procedure continued.
   
• Insecure position of the speculum on the incisor occlusal surfaces
  Suggestion: If necessary, incisor correction should be performed prior to cheek tooth extraction, for example after administration of the local nerve block.
   
• Unstable incisors due to periodontal disease/EOTRH
  Although the incidence might not be extremely high for this complication to occur, the author is aware of at least one accident in which the affected horse fractured all mandibular incisor teeth when the mouth was opened with a full mouth speculum. All fractured incisors showed severe pathologic changes indicative of EOTRH.
  Suggestion: Periodontal disease that has resulted in loosening of some/all incisor teeth should be diagnosed during oral examination. If the cheek tooth extraction cannot be postponed, a padded speculum resting on the interdental spaces could be used. Alternatively the cheek tooth extraction could be performed under general anesthesia.
   
• Postoperative complications due to incorrect use of the speculum
  Paralysis of the buccal branches of the facial nerve might be caused by excessively tightened straps of the full mouth speculum. Pressure applied to the cheek by hands or fists of an assisting person might also be a risk factor for postoperative facial nerve paralysis.
  Suggestions: The fit of the leather straps of the full mouth speculum should be checked and released when pressure in the parotid region or over the masseter muscle seems too high. The mouth should be closed in intervals during a time consuming oral extraction.

4.2. Complications during oral extraction

4.2.1. Complications elevating the gingiva

• Elevation of gingiva of neighboring teeth
  Excessive loosening of the gingival attachment of neighboring teeth results in the creation of periodontal pockets. Food particles might be entrapped in these pockets. Gingivitis and periodontal disease of the neighboring teeth might be the undesirable consequences of careless gingival detachment.
  Suggestion: Loosening of the gingival attachment should be performed carefully under visual control.
   
• Detachment of oral mucosa from maxillary/ mandibular bone
  Gingivitis, localized stomatitis or osteitis/ osteomyelitis might be initiated when dental picks or root elevators are inadvertently inserted deeply on the oral side of the alveolar processes instead of being wedged in between the tooth and the alveolar bone.
  Suggestion: The insertion of tooth picks or root elevators into the periodontal space should be performed carefully.
   
• Laceration of the greater palatine artery (A. palatina major)
  Suggestion: Careful handling of gingival elevators/sharp bladed picks is recommended. In case of laceration of the palatine artery compression should be applied to the laceration site with a finger or using a large swab or towel for a minimum of 10-15 minutes.² If bleeding continues after pressure release – reapply pressure with a towel for a longer time. 
  It is technically difficult to surgically ligate both ends of the vessel under field conditions. No time should be lost trying to perform surgical ligation.²

4.2.2 Complications during spreading

• Wrong position of the molar spreaders and use of excessive force results in damage of the tooth to be extracted or a neighboring tooth
  Depending on the extent of the dental fracture, the crown of the tooth to be extracted might be damaged to an extent which renders further attempts of oral extraction impossible. In this case an alternative technique of tooth removal (i.e. minimal invasive buccotomy or dental repulsion) has to be applied.
  If neighboring teeth are traumatized, the consequences might be negligible in case of superficial dental fractures. If pulp horns are exposed, pulpitis, pulp necrosis and apical infection might result, necessitating extraction of the traumatized tooth.
  Suggestion: The correct position of the spreaders in the interdental space should be visualized with an endoscope or a mirror (see in Proceedings: Endoscopy-Aided Extraction of Cheek Teeth, Simhofer). Force should only be applied to the handles of the spreader when “elastic” resistance is encountered.
   
• Spreader wedges are forced out of the interdental space during spreading
  Suggestions: Molar spreaders with narrow wedges should be applied if available. Additionally the speculum might be closed to an extent which allows resting the blades of the spreaders on the opposing cheek teeth row. In this way the instrument can be stabilized against slipping out of the interdental space. Spreaders should be applied as close to the gingival margin or even some millimeters apical to this point.
  Alternatively, a flat-bladed dental pick or root elevator might be forced between the teeth. Sufficient time should be invested until the interdental spaces have been enlarged effectively.
   
• Spreaders do not fit in the interdental space due to oblique interdental spaces and/or malpositioned cheek teeth
  No effective widening of the interdental space(s) can be achieved when spreaders cannot be used resulting in prolonged extraction time.
  Suggestions: Use alternative methods of widening of the interdental space (dental picks). Use custom modified (unilateral) spreaders.  [...]