available in the published literature [4, 20]. As a “third layer” of closure support, an interpositional material such as an allogeneic or autogenous bone graft, gold foil, or bioabsorbable material can be used. Recently, Watzak described a press fit, autogenous bone graft, technique for closure of OAF with a subsequent conventional sinus lift and implant placement [21]. Following surgery, the patient should be placed on sinus precautions for three weeks and continued on antibiotics, decongestants, and nasal saline irrigation, and monitored closely (Algorithm 2.4).
Injury to Adjacent Teeth/Wrong Tooth Extraction
Etiology: unrecognized adjacent tooth risks, failure to perform a timeout, or lack of communication
Management: repair of the adjacent tooth, communication with the patient and referring dentist, stabilization with suture, wire, or bonding
Fig. 2.2. (a) Preoperative appearance of a right OAF secondary to traumatic extraction. (b) Outline of planned FAMM flap to be used for reconstruction. (c) Following obliteration of the defect with the vascularized FAMM flap.
Algorithm 2.4: Oroantral Communication
The most common injury to an adjacent tooth is loosening or fracture of a large existing dental prosthetic restoration [3, 4]. Other injuries can include tooth loosening due to inappropriate use of elevators, crown fracture due to caries, and inadvertent extraction of an adjacent tooth [3, 4]. The incidence of injury to an adjacent second molar when performing third molar surgery is between 0.3% and 0.4% [1, 2, 5, 6]. Limited data exist regarding inadvertent extraction of an adjacent tooth specifically during third molar surgery, however; the overall incidence of wrong tooth extraction ranges from 0.026% to 0.047% [3]. The occurrence of wrong tooth extraction is likely increased with premolar extractions for orthodontic purposes, and this highlights the need for excellent communication between the surgeon and the referring dentist/specialist.
Fig. 2.3. Panoramic radiograph with teeth marked for extraction.
Adjacent teeth with large restorations, caries, or recurrent decay pose a significant risk for inadvertent injury. Evaluation of adjacent teeth both clinically and radiographically should be completed prior to beginning an extraction procedure, and patients should be made aware of the possibility of injury. If an adjacent tooth poses a high risk for injury, attempts should be made to avoid luxation with elevators adjacent to the tooth or consideration made for not using an elevator at all. To avoid injury to the opposing dentition during extraction, excessive traction forces should be avoided. If a tooth suddenly releases, this can result in iatrogenic instrument damage to the cusp tips or incisal edges of opposing teeth. Also, placing a finger or suction tip in between the forceps and opposing dentition can prevent contact with the instrument or absorb some of the blunt forces. Wrong tooth removal should never occur if adequate attention is given to planning and an appropriate timeout process. The tooth to be extracted should be marked on the radiograph and confirmed with both the patient and the assistant in terms the patient can also understand (Figure 2.3). The referring dentist/specialist should be contacted if confusion exists as to the correct tooth planned for extraction.
If an injury occurs, it should be treated promptly, and all parties involved should be notified. A fractured tooth or restoration can be temporized and the referring practitioner notified. Loosened or avulsed crowns can be recemented if no recurrent decay exists, or temporarily cemented if caries is noted. If an adjacent tooth is loosened, it should be repositioned and stabilized. Often, this requires only minimal repositioning and the tooth can be left alone. If significant loosening has occurred, stabilization for 10–14 days with the least rigid method of stabilization (nonrigid splinting with stainless steel wire and composite material) should be used to avoid the risk of ankylosis or root resorption. Extraction of the wrong tooth, if immediately noted, may be managed as a tooth avulsion. The tooth should be implanted back into the extraction site and stabilized with nonrigid splinting for 7–10 days. If the tooth is being extracted for orthodontic reasons, the remaining teeth should not be extracted and the referring orthodontist should be notified immediately [3]. Occasionally, modification of the treatment plan can be performed to utilize the tooth that should have been removed and treatment can proceed with the new plan. If the original tooth planned for extraction needs to be removed, health and stability of the accidentally extracted tooth should be confirmed prior to proceeding with further extractions. When the error goes unnoticed at the time of extraction, the tooth can obviously no longer be replanted. It is important to document thoroughly any case of wrong tooth extraction and inform all parties involved. According to Oral and Maxillofacial Surgery National Insurance Company (OMSNIC) data, 46% of all wrong‐site tooth extraction claims are settled with an indemnity payment. Thus, documentation and prompt communication with both the patient and referring dentist are important to avoid litigation.
Injury to Adjacent Osseous Structures
Etiology: excessive force, patient anatomy
Management: removal of devitalized bone, maintain bone with attached periosteal blood supply, separate teeth from bone, fixation of fractured bone
During the process of third molar extraction, and more specifically maxillary third molar extraction, the surrounding bone is at risk for inadvertent fracture. The most likely places for bone to fracture during removal of maxillary third molars are the buccal cortical plate and maxillary tuberosity. The incidence of maxillary tuberosity fracture in association with third molar extraction is approximately 0.6% and is most often caused by excessive force with forceps or elevators. The combination of type IV bone, no distal support, and often significant space involvement by the maxillary sinus all contribute to the potential for a tuberosity fracture [3, 22] (Figure 2.4).
Maxillary tuberosity fracture, or buccal cortical plate fracture, can compromise future prosthetic rehabilitation as the maxillary tuberosity is an important anatomical retention point for complete dentures. Buccal plate fracture can lead to soft tissue tearing and irregular remaining alveolar bone. To avoid these complications, the surgeon should ensure appropriate force application and remove bone in a controlled fashion when excessive force is necessary for extraction. In addition, placement of a periosteal elevator distal to the third molar to elevate the tooth and separate it from the periodontal ligament and tuberosity can assist the surgeon in avoidance of tuberosity fracture.
When a fracture of the buccal cortical plate occurs, the surgeon should assess the stability, size, and soft tissue attachment (periosteum) of the fractured segment. In general, if the periosteum is intact on the fractured bone segment, consideration should be given toward maintaining the bone segment, but if the periosteum is detached, the bone segment is a “nonvascularized” segment of bone, and the surgeon must weigh the risks and benefits of maintaining a devitalized