Complications of Tooth Extraction
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Direct answer
Complications of extraction are best organised by timing — intraoperative, early postoperative and late — because each window has its own shortlist and its own management. Intraoperatively the worries are tooth and root fracture, alveolar and tuberosity fracture, nerve injury, oroantral communication and haemorrhage; postoperatively the agenda is bleeding classified as primary, reactionary or secondary, alveolar osteitis, infection, trismus and oedema. Alveolar osteitis — the dry socket — with Birn's fibrinolytic pathogenesis, is the single most examined complication here.
What you must remember
- Primary haemorrhage occurs during surgery; reactionary bleeding classically appears two to four hours later as vasoconstrictor effect wears off; secondary bleeding at five to seven days reflects infection and clot degradation — this timeline is a standard viva question.
- Dry socket (alveolar osteitis): frequency about 0.5-5 per cent after routine extraction but up to roughly 25-30 per cent after mandibular third molar removal; severe pain at 2-4 days, fetor oris, denuded bone and absent clot; risk raised by smoking, traumatic surgery, oral contraceptives and mandibular site.
- Birn's fibrinolytic theory: bacterial and tissue activators convert plasminogen to plasmin, which lyses the fibrin clot — treatment is therefore irrigation, obtundent dressing (zinc oxide eugenol or medicated dressings such as Alvogyl) and review, not antibiotics or curettage.
- Oroantral communication: suspect after upper molar extraction; confirm gently (avoid vigorous nose-blowing tests), and manage by size — under about 2 mm may close over a clot with sinus precautions, intermediate defects need a figure-of-eight or collagen-supported closure, larger ones a buccal advancement, palatal pedicle or buccal fat pad flap.
- Nerve injuries: inferior alveolar and lingual nerves in the mandible; classify as neuropraxia, axonotmesis or neurotmesis; spontaneous recovery is the rule within 8-12 weeks for neurapraxia.
- Fractured tuberosity: manage by retaining the fragment with the tooth if still attached, splinting, or detaching the segment and smoothing; warn before extracting isolated upper molars in long-standing edentulous maxillae.
- Dislocation of the opposite TMJ, subcutaneous emphysema from air turbine use, and swallowed or inhaled teeth complete the intraoperative list — a chest radiograph is mandatory when a tooth goes missing.
How to work through a postoperative bleed
A patient telephones four hours after extraction with constant oozing. Sit them upright, reassure — anxiety raises blood pressure — and have them rinse gently once to clear clots, then bite firmly on a moistened gauze pad for twenty minutes. If bleeding persists on arrival, examine under suction and good light: a history of anticoagulants, liver disease or hypertension directs the systemic screen. Local measures follow a ladder — clean the socket of loose clot, place a haemostatic agent such as oxidised cellulose or tranexamic-acid-soaked gauze, close with a figure-of-eight or mattress suture, and only rarely pack the socket tightly. Take a postoperative haemoglobin and coagulation screen when history suggests it, and re-examine the adjacent soft tissue: a torn gum margin or a small vessel in the flap is a far commoner source of continued bleeding than the socket itself. Refer the patient who continues to bleed after these measures, or who bleeds with an unexplained coagulopathy, for haematological workup rather than repeated blind packing.
Where students slip
The dry socket answer is where marks leak. Candidates write "infection of the socket" — technically wrong, since alveolar osteitis is a fibrinolytic, inflammatory condition with bacterial involvement but not a spreading infection, which is precisely why antibiotics do not cure it and why curettage to induce fresh bleeding is debated rather than routine. A second slip is the oroantral fistula question: examiners ask how long a small communication takes to epithelialise into a permanent fistula — within about two weeks if it fails to close — and which flap suits which defect. A buccal advancement flap shortens the vestibule; the palatal pedicle on the greater palatine artery is robust but bulky; the pedicled buccal fat pad is the modern workhorse for larger posterior defects.
Frequently asked questions
What distinguishes reactionary from secondary postoperative haemorrhage?
Reactionary bleeding occurs within hours as vasoconstrictor effect fades; secondary bleeding appears around five to seven days, driven by infection destroying the clot.
What is the pathogenesis of dry socket per Birn?
Plasminogen activators of bacterial and tissue origin generate plasmin, which lyses the fibrin clot, leaving denuded bone that is exquisitely painful.
How is a dry socket treated?
Warm saline irrigation, gentle debridement, and an obtundent dressing such as zinc oxide eugenol, replaced every few days until granulation covers the bone — analgesics and review, not antibiotics.
When does an oroantral communication need a flap?
Beyond about 3 mm, or any persisting despite two weeks of sinus precautions.
Which nerves are injured in lower third molar surgery?
The inferior alveolar nerve (lip and chin) and the lingual nerve (tongue, plus taste loss when chorda tympani fibres are involved).
What is done when an extracted tooth is inhaled?
Immediate chest radiograph — a right lower lobe location is typical — and referral for bronchoscopic removal.