Tooth extraction, especially surgical extraction, is among the most frequently performed procedures in our clinics. While most of these procedures go smoothly without incident, there are times when unexpected situations arise that truly test our composure and expertise. These “complications” are an inherent part of our work. More importantly than fearing them, it’s about thoroughly understanding them and knowing precisely how to act when they do occur.
When a problem arises during an extraction, your immediate response in those first few crucial minutes will dictate everything: the patient’s safety, the treatment outcome, and even the reputation of your practice.
In this article, we’re going to break down the most common complications you might encounter during an extraction. We’ll provide step-by-step guidance on how to manage them, and perhaps even more importantly, when it’s time to tell a patient, “No, this situation requires a specialist.”
1. Root Fracture: The Most Common Dread
This is undoubtedly what makes most of us anxious. You’re performing an extraction, and suddenly, you hear a “snap”… the crown comes out in your hand, but the root is still stubbornly lodged inside. Your immediate thought is, “What now? Do I have to remove it, or can it be left alone?”
The decision here isn’t based on preference; it’s a scientific judgment rooted in your comprehensive assessment of the case.
When Can You Potentially Leave a Fractured Root?
In specific scenarios, deciding to leave a small root fragment might actually be safer for the patient than attempting to remove it. These conditions include (1):
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Size of the Fractured Piece: If it’s a very small fragment from the apical third of the root, specifically less than 5 mm.
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Tooth Condition: If the tooth was vital and there’s absolutely no associated inflammation or periapical lesion visible on the radiograph.
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Proximity to Vital Structures: If the root is extremely close to critical vital structures, such as the Inferior Alveolar Nerve or the Maxillary Sinus, and attempting its removal could cause permanent damage, like lip paresthesia.
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Extent of Bone Removal: If extracting this tiny fragment would necessitate extensive surgical excavation and excessive bone removal, then the potential harm outweighs the benefit.
The Most Crucial Step: If you opt to leave the root, you must explain the situation candidly to the patient, helping them understand why this decision is currently the best course of action for them. Furthermore, you need to thoroughly document this in the patient’s file, both in writing and with a post-extraction radiograph. Also, ensure they understand that if the root causes any issues in the future, it can certainly be removed then.
When Must You Remove a Fractured Root?
If any of the conditions mentioned above are not met, then removal is mandatory. This means if the fractured piece is large, or if the tooth had pre-existing inflammation, or if you can easily visualize it and removal won’t require significant bone removal.
2. Luxation of an Adjacent Tooth (Accidental Dislocation)
This unfortunate mishap often occurs due to haste or the application of incorrect force. You might be using an elevator, leaning on an adjacent tooth, and suddenly notice that healthy tooth has become mobile.
Immediate and Correct Action:
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Reposition Immediately: Your first and foremost action is to gently reposition the tooth back into its socket.
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Secure It Firmly: You must stabilize this tooth by splinting it to the adjacent teeth using a flexible wire-composite splint.
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Ensure Out of Occlusion: Make certain that this tooth is completely out of occlusion so the patient doesn’t exert any pressure on it during biting.
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Strict Patient Instructions: Advise the patient to avoid eating on that side for two weeks and to refrain from touching the tooth with their tongue.
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Follow-up is Key: It is imperative to follow up with the patient after two weeks to confirm the tooth has stabilized, and perform a vitality test to ensure it doesn’t require Root Canal Treatment (2).
3. TMJ Dislocation (Temporomandibular Joint Dislocation)
This typically happens during lower molar extractions, often when excessive force is applied to the Mandible without adequate support. Suddenly, you find the patient is unable to close their mouth after the procedure.
Calm and Professional Management:
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Reassure the Patient First: Calmly inform them that this is a minor issue and you’ll reposition it immediately.
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Proper Mandible Grip: Stand in front of the patient. Wrap gauze around your thumbs for protection and place them firmly on the occlusal surface of the mandibular posterior teeth. Your remaining fingers should be positioned underneath the mandible to provide support.
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Execute the 3 “Magic” Movements: This maneuver must be performed confidently and in one fluid direction:
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Downward: To disengage the condyle from where it’s caught.
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Backward: To guide the condyle back into its proper place.
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Upward: To seat and stabilize it in the fossa.
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Crucial Advice: After reducing the joint, you might consider applying a light compression bandage around the patient’s head and jaw to prevent wide opening for 24 hours. Advise them to consume a soft diet.
4. Swallowing or Aspiration of the Tooth
This is a terrifying scenario for both you and the patient. Suddenly, the tooth slips from the forceps, and the patient swallows it. Here, you absolutely must determine its destination: the digestive system or the respiratory system?
Immediate Action Protocol (3):
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Encourage Coughing: First, lean the patient forward and strongly encourage them to cough forcefully. If the tooth has entered the initial part of the trachea, coughing might dislodge it.
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If Coughing is Ineffective: You must immediately send the patient for a Chest X-ray to accurately locate the tooth.
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If in the Respiratory System: This constitutes a medical emergency. The patient must be transferred to a hospital immediately for bronchoscopy and tooth removal. Any delay here is extremely hazardous.
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If in the Digestive System: This situation is generally calmer. In most cases, the tooth will pass naturally with bowel movements. Your responsibility is to follow up with the patient every three days for two weeks to confirm its passage.
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Danger Signs: It is critical to instruct the patient to contact you or seek emergency medical attention immediately if they experience any chest pain, sudden and severe coughing, or a fever.
The Takeaway: A Prepared Dentist Handles Problems
Tooth extractions are not always straightforward or simple. These complications can genuinely occur to even the most skilled dentist. The pivotal difference between a highly professional practitioner and an average one lies in preparedness, maintaining composure, and the ability to act correctly at the right moment. By knowing the precise steps to handle each potential issue, you can transform a daunting situation into an experience that truly solidifies your expertise and, most importantly, further earns your patient’s trust.
