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Original Research

Complications of exodontia: A retrospective study

Gokul Parameswar Venkateshwar, Mukul Nandkumar Padhye, Aman Rajiv Khosla, Shruti Tejprakash Kakkar

Department of Oral and

Maxillofacial Surgery,
ABSTRACT
Padmashree Dr. D. Y. Patil Purpose: The purpose of this study was to analyze the incidence of various complications
Dental College and Hospital,
Dr. D. Y. Patil University, Nerul,
following routine exodontia performed using fixed protocols.
Navi Mumbai, India 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
Received : 20‑10‑10 accordingly.
Review completed : 30‑12‑10
Accepted : 03‑07‑11 Key words: Complications, dry socket, exodontia, tooth displacement

Exodontia is the most common surgical procedure performed like displacement of a root fragment in the maxillary sinus
in the speciality of Oral and Maxillofacial Surgery. and oro‑antral fistula [Table 1].

Complications are unforeseen events that tend to increase the Careful attention to details including a thorough case
morbidity, above what would be expected from a particular history, routine investigations like radiographs and blood
operative procedure under normal circumstances.[1] Though investigations is an inherent part of exodontia. Adjunctive
they are rare, their occurrence leads to a prolonged phase investigations like a Cone Beam Computed Tomography
of treatment, which is cumbersome to the patient as well (CBCT) scan can be performed to assess the difficulty of a
as the clinician. case. These investigations can pre‑warn a clinician about
any impending complication.
The dictum that to prevent a complication from occurring
is the best way to manage one remains time tested. Thus, it The purpose of this study was to analyze the incidence and
becomes imperative that the clinician is aware and recognizes distribution of complications following routine extractions
the whole spectrum of complications and their implications. performed in the Department of Oral and Maxillofacial
Surgery at Padmashree Dr. D. Y. Patil Dental College and
Complications can be wide, ranging from common ones like Hospital, Nerul, Navi Mumbai.
dry socket and root fracture to uncommon and serious ones
MATERIALS AND METHODS
Address for correspondence:
Dr. Aman Khosla A retrospective study of 22,330 extractions carried out in
E‑mail: [email protected] 14,975 patients who reported to the Department of Oral and
Maxillofacial Surgery at Padmashree Dr. D. Y. Patil Dental
Access this article online College and Hospital was conducted.
Quick Response Code: Website:
www.ijdr.in The study included 8464 males and 6511 females, with age
ranging from 14 to 82 years with a mean age of 41 years.
PMID:
***
Only healthy individuals were included in the study.
DOI: Medically compromised patients, pregnant and lactating
10.4103/0970-9290.93447
mothers were excluded from this study.
633 Indian Journal of Dental Research, 22(5), 2011
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Complications of exodontia: A retrospective study Venkateshwar, et al.

Only simple extractions requiring simple elevation and Table 1: Articles showing incidence of complications of
forceps application were included in the study. More simple tooth extraction
complex extractions requiring reflection of soft tissue flaps Topic Journal
and surgical bone removal for extraction of the teeth were Dry socket SADJ
2008;63:490,492‑3
excluded from the study. Does prophylactic administration of systemic J Oral
antibiotics prevent postoperative inflammatory Maxillofac Surg
The causes for the extraction of teeth have been enumerated complications after third molar surgery? 2007;65:177‑85
in Table 2. The anatomic distribution of the extracted teeth Incidence and pattern of presentation of dry Nig Q J Hosp Med
socket following non‑surgical tooth extraction 2007;17:126‑30
has been shown in Table 3. Incidence of dry socket, alveolar infection, and J Contemp
postoperative pain following the extraction of Dent Pract
In all cases, 2% lignocaine hydrochloride with 1:80,000 erupted teeth 2010;11:E033‑40
adrenalin solution was used to provide anesthesia. Prevalence of complications of simple tooth JNMA J Nepal
extractions and its comparison between a Med Assoc
tertiary center and peripheral centers study 2007;46:20‑4
Local infiltration, infraorbital nerve block, posterior superior conducted over 8,455 tooth extractions
alveolar nerve block or inferior alveolar nerve block were Influence of trans‑operative complications on J Contemp Dent
used depending upon the anatomic distribution of the teeth socket healing following dental extractions Pract 2007;8:52‑9
Topical antibiotic prophylaxis for bacteremia Oral Surg Oral
to be extracted. after dental extractions Med Oral Pathol
Oral Radiol Endod
A maximum of 5 ml of local anesthetic solution was injected 2001;91:162‑5
in each patient. Bacteremia following tooth extractions Rev Stomatol
Chir Maxillofac
1976;77:849‑56
All patients in the study group were prescribed antibiotics and Pain experience after simple tooth extraction J Oral Max Surg
analgesics and explained about wound care postoperatively. 2008;66:911‑7

Postoperatively; all patients were prescribed antibiotics, Table 2: Cause for extraction of tooth
i.e. amoxycillin (250/500 mg) or a combination of Cause Number of extractions Percentage
amoxycillin (250 mg) + cloxacillin (250 mg), depending on Caries 6763 30.3
the severity of the infection. Periodontitis 6242 27.9
Orthodontic 3304 14.8
Trauma 1753 7.9
All patients were prescribed antibiotics postoperatively as Endodontic failure 1512 6.8
all the extractions were performed by undergraduates and Non‑functional 1319 5.9
interns, resulting in longer, more traumatic extractions, Iatrogenic 720 3.2
Miscellaneous 717 3.2
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 Table 3: Anatomic distribution of teeth extracted
Maxillary Maxillary Mandibular Mandibular
patients presented with pre‑existing infection that needed
anteriors posteriors anteriors posteriors
to be controlled.
Number of teeth 5140 6252 3568 7370
Percentage 23 28 16 33
Patients were asked to resume oral hygiene habits (tooth Anterior = central incisor to canine, posterior = first premolar to third molar
brushing two times per day) 24 hours postoperatively.
• Fracture mandible
Tobacco smoking history was not included in this study. • Hemorrhage
• Displacement of tooth/root in the maxillary antrum
In cases where suturing was required, 3‑0 silk was used to • Displacement of tooth/root into adjacent tissue space
achieve closure. • Dry socket
• Trismus
The cases were distributed randomly to the operators. • Postoperative pain
• Infection
The extractions carried out were evaluated for the following • Wound dehiscence
complications:
• Fractured tooth Fractured tooth included crown and/or root fracture.
• Laceration
• Soft tissue injury Hemorrhage included only primary hemorrhage.
• Luxation of adjacent tooth/teeth
• Fracture of cortical plates Cortical plates included both buccal (labial) and lingual
• Fracture of maxillary tuberosity (palatal) plates.
Indian Journal of Dental Research, 22(5), 2011 634
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Complications of exodontia: A retrospective study Venkateshwar, et al.

Dry socket was defined as postoperative pain inside and Complications

around the extraction site, which increased in severity at The complications noted are given in Tables 4‑7 and
any time between the first and third day after the extraction, Figures 3‑7.
accompanied by a partial or total disintegrated blood clot,
with or without halitosis. Thus, in this study, it is seen that the major causes of
extraction were caries and periodontitis, followed by
Healing was assessed by clinical examination of the patient, orthodontic purposes, trauma and endodontic failure.
as well as patient feedback regarding pain, halitosis,
dysgeusia, etc. The largest number of extractions was carried out in the
mandibular posterior segments, followed by the maxillary
RESULTS posterior segments, the maxillary anteriors and finally the
mandibular anteriors.
Between October 2007 and September 2010, 23,242
extractions were carried out in 15,817 patients in the Also, it was observed that the fracture of tooth is the most
Department of Oral and Maxillofacial Surgery [Figure 1]. common complication, followed by trismus, fracture
of cortical plates and dry socket. Wound dehiscence,
Extractions in medically compromised/pregnant/lactating postoperative pain and hemorrhage showed a medium
patients = 912 extractions in 842 patients. incidence. Luxation of adjacent teeth, displacement of tooth
into maxillary antrum/adjacent tissue spaces, infection and
Sample size = 22,330 extractions in I4,975 healthy patients fracture of maxillary tuberosity were comparatively rare
[Figure 2]. complications.
Table 4: Incidence of the complications No cases of fracture mandible were recorded.
Complication Number
Fractured tooth 4566 A higher incidence of complications was seen when
Lacerations 902
Soft tissue injuries 1818 undergraduates carried out the extractions, compared to the
Fracture of cortical plates 3607 interns; when the operative time exceeded 30 minutes as
Trismus 4023 compared to procedures completed within 30 minutes; and
Dry socket 2618 when the extractions were carried out in the mandibular
Wound dehiscence 779
Postoperative pain 864 arch as compared to the maxillary arch.
Hemorrhage 289
Fracture of maxillary tuberosity 112 DISCUSSION
Luxation of adjacent tooth 28
Fracture mandible 0
Although careful attention to surgical details, including
Displacement of tooth into maxillary sinus 9
Displacement of tooth into adjacent spaces 12 proper patient preparation, asepsis, and meticulous
Infection 86 management of hard and soft tissue, controlled force when
applying surgical instruments, hemostasis and adequate
postoperative instructions, may help to reduce the rate of
Table 5:Distribution of the complications between interns
and undergraduates complications, it has not been found to eliminate them.
Student No of No of Chi‑square P value
extractions complications value
The factors that contribute to such complications are
(%) (%) numerous and include the patient or may be tooth related,
Intern 10,718 (48) 7291 (37) 518.098 0.000 and also include the surgeon’s operative experience.[2,3]
Undergraduate 11,612 (52) 12,422 (63) Other factors found to affect the complication rate include
Total 22,330 19,713 age[4] and gender[5] of the patient.

Table 6: Relation between time taken for the procedure and number of complications
Time taken for Number of Number of Percentage of Chi‑square P value
the procedure extractions (%) complications complications value
0–30 min 10,940 (49) 6898 35 839.574 0.000
30–60 min 11,390 (51) 12,815 65

Table 7: Incidence of complications in maxilla and mandible

Location of teeth No of teeth extracted (%) No of complications (%) Chi‑square value P value
Maxilla 11,392 (51) 8873 (45) 151.009 0.000
Mandible 10,938 (49) 10,840 (55)

635 Indian Journal of Dental Research, 22(5), 2011

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Complications of exodontia: A retrospective study Venkateshwar, et al.

Figure 1: Total no. of patients from October 2007 to September 2010 Figure 2: Excluded and included patients

5000 4566
4500 4023
4000 3607
3500
3000 2618
2500
2000 1818
1500
1000 902
500
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Fractured tooth Laceration Soft Tissue injury

Fracture of cortical plates Dry Socket Trismus

Figure 3: Bar graphs showing a comparison of the complications Figure 4: Donut chart showing a comparison of complications occuring
occuring with a high frequency with a high frequency

Figure 5: Pie chart showing a comparison of complications occurring Figure 6: Pie chart showing a comparison of complications occurring
with a medium frequency with a low frequency

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%,[6‑9] while its
incidence after extractions of third molar varies from 1 to
Figure 7: Conical graph showing a comparison of complications 37.5%.[10,11] Increased occurrence is seen in smokers[12‑14] and
occurring with a low frequency patients on oral contraceptives.[15‑17]

Indian Journal of Dental Research, 22(5), 2011 636

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Complications of exodontia: A retrospective study Venkateshwar, et al.

Trismus is an objective finding, and thus difficult to measure Following the axiom “prevention is better than cure”[26] still
objectively despite being readily observable.[18] remains the best way to manage any complication.

Postoperative pain (3.9%), wound dehiscence (3.5%) and Undergraduate includes third and final year students
hemorrhage (1.3%) were the less frequent complications.
Null hypothesis
A 100‑mm visual analogue scale (VAS) was used for the There is an association between column and row attributes
assessment of postoperative pain,[19] 2 days and 7 days
postoperatively. The patients described the character of Interpretations
pain as constant, shooting, or dull while chewing. The Since P‑value is very small and less than 0.05, we reject
assessment was done within 15 min of administration of null hypothesis of no association and conclude that there
the pain medication. is relationship between column and row attributes, i.e.
operator experience, time taken for the procedure, arch in
Fracture of maxillary tuberosity (0.5%), infection (0.4%), which the procedure is performed and number of extractions
fracture mandible, luxation of adjacent tooth (0.13%), and number of complications
displacement of tooth into adjacent tissue spaces (0.05%)
and displacement of tooth into maxillary sinus (0.04%) were Null hypothesis
some of the rarer complications. There is an association between column and row attributes

The maxillary tuberosity is an important retentive area for Interpretations

maxillary complete dentures and every effort must be made Since P‑value is very small and less than 0.05, we reject
to preserve it. null hypothesis of no association and conclude that there
is relationship between column and row attributes, i.e.
The accidental displacement of teeth into fascial spaces operator experience, time taken for the procedure, arch in
constitutes an unusual complication. However, there are which the procedure is performed and number of extractions
reports in the literature of displacement of teeth into the and number of complications
infratemporal fossa,[20] maxillary sinus,[21] submandibular
space,[22] pterygomandibular space,[23] lateral pharyngeal Null hypothesis
space,[24] and lateral cervical region.[25] There is an association between column and row attributes

A higher incidence of complications was probably seen as Interpretations

the operators were the lesser experienced undergraduates Since P‑value is very small and less than 0.05, we reject
and interns. Also, a higher incidence of complications was null hypothesis of no association and conclude that there
seen when extractions were carried out by undergraduates is relationship between column and row attributes, i.e.
(63%), as compared to interns (37%). operator experience, time taken for the procedure, arch in
which the procedure is performed and number of extractions
The amount of time required to complete the procedure and number of complications
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18. Norholt SE, Aagard E, Svensson P, Sindet Pederson S. Evaluation Source of Support: Nil, Conflict of Interest: None declared.

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