We’ve now come to the last bit of this 3-part Oral Surgery Complication series with Dr. Chris Waith. I’m going to be honest, I have a lot of concerns about Tuberosity Fractures – they scare the bejeebers out of me! We all know that it can be a really nasty complication. Fear not! Dr Waith will teach you how to prevent and manage maxillary tuberosity fracture.
“If there’s a really tight contact between those three molars, the two teeth you’re extracting, just spend a minute skimming the contact points.“ – Dr Chris Waith
In this episode, we discussed about:
- Risk factors of tuberosity fractures 1:40
- How to manage when you hear the crack of the tuberosity 3:57
- High risks patients 6:35
- Leaving a loose bone as a space filler in soft tissue 9:07
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If you loved this episode, be sure to check out the first part! Dry Sockets – How to Prevent and Manage Them?
Click below for full episode transcript:Opening Snippet: Welcome to group function, where the Protruserati worked together to find good solutions to worthy problems in dentistry with your host, Jaz Gulati...
Jaz’s Introduction: Tuberosity fractures are super scary, like, you know, when we did the first group function with Chris Waith about dry sockets, dry sockets don’t worry me, okay? When it comes to OACs, Yeah, a little bit concerning, but after that episode, I feel much more confident. But when it comes to Tuberosity Fractures, man, I have to tell you, I’m really worried about causing them. And I’ve seen on social media people posting these photos, you know, I try to take out the upper left molar, and then the whole premolars and all the molars came out with it. And that is a scary sight. So in this group function, we’re going to ask Chris Waith, how to prevent and how to manage that dreaded tuberosity fracture. Let’s hit it.
Main Interview: [Jaz]
Then the next one is and the last one is tuberosity fractures. Like, this is scary when you see on social media, some you know, sometimes a big group of people posting their tuberosity fractures, and you see the first molar, the second molar and a third molar, come out with this massive chunk of maxilla. I do not want to ever be in that position that must be so stressful and like how do you even begin to have that conversation like you know, we always warn our patients before doing an extraction, maxillary extraction about these kinds of things. But Never Have I Ever warned a patient that look me taking out this wisdom tooth, I might also take out three other teeth while I’m doing this, for example, it’s just so rare, unfortunate. So what are the risk factors? How can we manage it when you hear that crack, and so on and so forth.
So, I’ve been in that scenario of having a big unit, I think, if ever, you’re taking out an upper six, or upper seven. And if there’s a really tight contact between those three molars, the two tooth you’re extracting, just spend a minute skimming the contact points out. So drill the contact points, make a physical space in between that tooth and the two neighboring teeth. Because then when you’re Elevate, you’re much less likely to engage the your neighbor and hopefully less likely to put stress on a wider area of alveolus. I think if you just take in the wisdom tooth out, look for the risk factors. And you know, I sometimes go on when I’m teaching that I say I feel bad now about how we used to teach the undergraduates because there was definitely this mentality where you gave them some notes and just said take that. I’m probably didn’t spend long enough saying this is how you should take that type. And I think of parades is one of those where depending where you went, somebody would have put a cryers in your hand or a coupland and would have just said just push back, actually, that that’s a good way to fracture tuberosity because you’ve got two really powerful instruments, you can deliver a real large amount of energy and in the wrong patient, it will be energy in an area that’s very vulnerable. So low sinus, thin alveolar bone, difficult root morphology, elderly patient, long standing molar, existing Perio pathology, the more of those you tick, the more likely it is to happen. I think if you start to tick those, change your technique that will be the main thing. So instead of just trying to push it back, think do I use like a small luxator and try and push the buccal plates off the tooth so that there maybe I could get my bayonets and forceps in and just try and take it buccally instead of pushing it backwards. I think one easy thing to do, whether you use a mitchells or a flat plastic or something, just push the buccal gingiva off the tooth, push the distal gingiva off the tooth, push the palatal gingiva off the tooth. And then the logic is if you hear that dreaded crack, what you want is to just crack the bone and not tone all of the soft tissues. And like, if you’re mid extraction, the place you want to watch is the palatal side of your upper eight and seven. So as you’re pushing, in the bone, you’ll be causing little micro fractures, and then that big crack, that’s the macro fracture where you’ve got an actual break. The micro fractures you’ll see it in the palate and the palate will be pulsing, it will just be bulging a little bit and if you’re palate bulging in your head, you’ve got to think, right, so what I’m doing now, I need to not do that. I’ve got to change whatever energy I’m putting on there. Now if the tooth’s not moving and you see that, that might be the one that you say you know what let’s stop before some damage. [Jaz]
And maybe in that case, you’re gonna go, you’re gonna follow the trauma guidelines. You’re gonna put like a stainless steel like a splint wire on and composite bonded like, right? [Chris]
Splint it if you can. Get your High speed, drill the cusps off the eight. So it’s out occlusion, so that it’s not going to hurt when you keep biting on it, and refer it on, then wait 6, 7, 8 weeks, let all those micro fractures repair themselves. And they’ll approach the tooth a different way. So I take that, buccally if I could, or may even raise a flap and take some bone away to try and take it buccally. If it’s gone too far, if you hear the crack, tooth is loose, and it’s got to come out. The reason we’ve pushed those tissues away is to try and make sure that they’re intact, so that as you deliver the tooth, the tooth and the tuberosity, or is all that you’ve got a not like palatal gingiva, buccal gingiva. So the idea is, then once the tooth is out, hopefully, you’ve got gingiva either side of your socket, that you might just put a couple of stitches and then just pull those edges together. So that if there’s any airway see in there as well. Or if you want to put collagen cube, and if it’s bleeding, you’ve got proper kind of soft tissue support over the top. I think if you don’t look after the soft tissues, you chasing your tail a little bit then because then you really struggling to suture it, and you’ll already be shaking because of what’s happened. So it all starts to get a bit messy. And then I think tuberosity wise, even, I’d like, I think I’m uber-cautious when it comes to surgery. And I always expect the worst things happen. And even though I do, I still fracture tuberosity not loads, but you know, twice, three times a year. [Jaz]
You’re seeing the most difficult patients, you’re in a referral practice, you are seeing the, you know, if any GDP suspects it could happen. They’re probably sending it to you. [Chris]
Yeah. So my clientele probably is a prerequisite [Jaz] Higher risk [Chris] Yeah those. The tuberosity fractures differentiate quite a bit, there’s an article in dental update a few months ago, which was trying to classify them and I kind of get the logic, there’s, you know, there’s small bits of almost gristle stuck to the tooth, which is almost here and there. And then there will be the gristle and then a larger bit of bone. And then there’s the huge unit of bone. And it’s the huge unit of bone. And it’s really, it’s not so much that the bone is gone. And that’s the problem. It’s the fact that behind that, you’ve got things like your pterygoid plexus, and these bits of blood vessel, that if they traumatized in a big tuberosity fracture, it’s the bleeding that is the concern, because actually [Jaz] Hematomas and internal bleeding [Chris] We’re gonna really struggle to control that. So if ever it happens, I think, you know, do what I said try and preserve the soft tissue, you take the tooth out, before you do anything, just stop and just spend half a minute staring into the socket, and actually just see how it’s bleeding. And if it’s normal kind of socket, it is great, collagen cube, suture over the top of it, review the patient and just make sure they’re okay. If it’s bleeding heavily, just have in your mind side that that might be something behind the tuberosity, which we don’t want to bleed. So then, you know, you may even put Surgicel in but put something in, suture it tightly. But I think that’s the patient that you get on the phone to your local hospital and just say, can you see this patient? Touchwood, I’ve never seen that. But that’s the thing that we’re where we debate when they say fractured tuberosities. I think, you know, much like we’ve just said about OACs, most tuberosity fractures are relatively simple. It’s just the complicated ones that would be cautious about [Jaz]
I mean, the whenever I see a high risk patient, I do exactly what you say, the very first place I start is just dissecting the soft tissue away, you know, buccal, distal, palatal for that reason, what you don’t want is the bony complication or the fracture compounded with an inability for you to tidy that up because now everything looks like a massive soft tissue mess. So that is a great point. And the other thing is that let’s say you hear that crack, and now you’ve got a mobile fragment, your soft tissues are okay, but actually, it’s a fair chunk of bone, maybe not, you know, many teeth, just the wisdom tooth or the second molar and a chunk of bone distal to it, the tuberosity. At that point, I think you’re pretty much committed to just remove the entire portion of that loose bit, or would you say there’s any merit in now? Maybe a bit too late now, ie go back and listen to section and elevating because maybe that’s one way that we can prevent these things is like, okay, yeah, you did section and elevate, now the tooth is loose. And the bit of bone is loose, is it then worth carefully sectioning the roots where drilling the tooth away so that you leave that bone as some sort of, I guess, a space filler in the soft tissue? [Chris]
I don’t think so. I think even moving away from tuberosities, just bone in general in a socket. If you have some socket bone that is firmly attached to periosteum. And if you suture the socket and that bone is more or less where it started, then it’s got a reasonable chance to survive and as long as you’ve not traumatized it too much. I think as soon as a trauma increases, or if that bit of bone is actually quite loose within the socket, you may as well take that because it’s not got the constant support and keep in still that it needs for the bones. And the worst thing is that if while things are healing, it peels off, either it starts to poke through the gingiva, or it just floats around in the socket and gets infected then. I think in the tuberosity situation, of all the areas in your mouth, I think that’s the most difficult to stick your drilling. So if you’re in that scenario, your soft tissues are probably already torn, you’re having to raise a flap in an area where you don’t really want to raise the flap and use a drill in an area, you don’t really want to use a drill. So it’s another kind of avoidance is better than cure. I think if you’ve got that scenario, make sure all your soft tissues are well out of the way because potentially what’s on the end of that tooth is going to be bigger than the socket opening. And then very carefully, get it out of the socket. Watch it for the, sorry, watch it that to see if it’s bleeding and then suture across there and follow up. I think always always with those patients, give them sinus instructions, because there’s that chance that there might be a communication as well. Call them the next day and just make sure they’re okay. Call them a week later, make sure they’re still okay. I think if you’ve done that, you’ve at least shown the patient that you care, and you’ve acknowledged everything. But if there’s any complication you don’t see you can deal with, nip it in the bud early. [Jaz]
Amazing. Chris, you’ve answered all my oral surgery complication questions. These are main ones that we had from our telegram group. Are you on Telegram, Chris? [Chris]
No, I don’t even know what that is. [Jaz]
Okay, so you have WhatsApp? Right? [Chris] Yeah [Jaz] Okay, so telegram is like, the wiser, sexier cousin of WhatsApp. And you know, when there was a massive outage yesterday, you know, guess what our telegram group was on fire. Right? So, I’ll say you a download it. It’d be great to have you on, you know, those of is like, over 400 of us Protruserati on there. And there we’ve got Pav on there giving implant advice. We’ve got loads of great dentists on there. To have like an oral surgeon on there just to give us advice will be amazing. But I understand if you’re too busy, but if you want to join our telegram group, if anyone wants to join our telegram group, it’s for the Protruserati, it’s protrusive.co.uk/telegram and as long as you had the telegram app it will take you to your, to our group. So I’ll send you the invite Chris and by the way, see you in a few days in Brighton for the Tubules Congress and thanks so much for doing this really appreciate all those group function. [Chris]
No problem. It’s been a pleasure.
Jaz’s Outro: Well, there we have it. I hope you enjoyed this group function series all about oral surgery complications. Please do email me firstname.lastname@example.org, if you have any suggestions for future episodes, always love hearing from you guys. And of course, please give the show a five star rating if you’re listening on Apple. Thanks so much, guys. I’ll catch you in the next episode.