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A Potential Devastating Complication! IATROGENIC OCULAR TRAUMA I atrogenic trauma to ocular structures may occur during extraction of the maxillary fourth premolar, first molar, or second molar teeth. The cause of such trauma is related to the thin alveolar bone and proximity of the ventral floor of the orbit combined with technique that is too forceful. Another contributing factor may be that the clinician is unaware of the degree of periodontal pathology that may be present in the area decreasing the bony integrity of the ventral floor of the orbit (Fig. 1). Ocular structures adjacent to the caudal maxillary teeth may be perforated by a pointed instrument such as a periodontal elevator, especially in patients with destructive periodontal disease (Fig. 2). Panophthalmitis may result from perforation of the globe by the periodontal elevator. If antimicrobial and anti-inflammatory treatment fails, enucleation is an unfortunate result. Other complications from iatrogenic orbital trauma include periocular skin necrosis and brain abscessation (Figs. 3 and 4). This complication is preventable by using controlled force and a palm grip on the periodontal elevator with fingers placed near the working end or tip of the instrument. This grip limits accidental penetration of the instrument to the distance between fingers and the tip of the instrument (Fig. 5). Also, angling the periodontal elevator perpendicular to the tooth roots, instead of parallel, avoids accidental orbital penetration. Preoperative dental radiographs allow the clinician to assess the degree of periodontal bone loss. Although careful technique is always warranted during tooth extraction, evidence of periodontal pathology alerts the clinician to be especially diligent in adherence to proper extraction techniques. 1 2 3 . . . California Veterinarian | May/June 2011 46 by Mark M. Smith, VMD, DACVS, DAVDC

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Page 1: IATROGENIC OCULAR TRAUMA - CVMAcvma.net/wp-content/uploads/2014/10/OcularTrauma.pdf · IATROGENIC OCULAR TRAUMA I atrogenic trauma to ocular structures may occur during extraction

A Potential Devastating Complication! IATROGENICOCULARTRAUMA

Iatrogenic trauma to ocular structures may occur during extraction of the maxillary fourth premolar, first molar, or second molar teeth. The cause of such trauma is related to the thin alveolar bone and proximity of the ventral floor of the orbit combined with technique that is too forceful. Another

contributing factor may be that the clinician is unaware of the degree of periodontal pathology that may be present in the area decreasing the bony integrity of the ventral floor of the orbit (Fig. 1).

Ocular structures adjacent to the caudal maxillary teeth may be perforated by a pointed instrument such as a periodontal elevator, especially in patients with destructive periodontal disease (Fig. 2). Panophthalmitis may result from perforation of the globe by the periodontal elevator. If antimicrobial and anti-inflammatory treatment fails, enucleation is an unfortunate result.

Other complications from iatrogenic orbital trauma include periocular skin necrosis and brain abscessation (Figs. 3 and 4). This complication is preventable by using controlled force and a palm grip on the periodontal elevator with fingers placed near the working end or tip of the instrument. This grip limits accidental penetration of the instrument to the distance between fingers and the tip of the instrument (Fig. 5). Also, angling the periodontal elevator perpendicular to the tooth roots, instead of parallel, avoids accidental orbital penetration.

Preoperative dental radiographs allow the clinician to assess the degree of periodontal bone loss. Although careful technique is always warranted during tooth extraction, evidence of periodontal pathology alerts the clinician to be especially diligent in adherence to proper extraction techniques.

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. . . California Veterinarian | May/June 201146

by Mark M. Smith, VMD, DACVS, DAVDC

CV65_3.indb 46 5/3/11 4:06 PM

Page 2: IATROGENIC OCULAR TRAUMA - CVMAcvma.net/wp-content/uploads/2014/10/OcularTrauma.pdf · IATROGENIC OCULAR TRAUMA I atrogenic trauma to ocular structures may occur during extraction

Figure Legends

Figure 1 –Dental radiograph showing severe bone loss secondary to periodontal disease. Note the bone loss around the right maxillary first molar tooth.

Figure 2 –Photograph showing how a periodontal elevator can be directed into the orbit.

Figure 3–Panophthalmitis and skin necrosis in a dog that had a perforated globe as a complication of extraction.

Figure 4 –CT scan showing a brain abscess (arrow) following orbital and cranium penetration with a periodontal elevator.

Figure 5–Correctly held periodontal elevator with the grip location limiting instrument advancement (A) compared with a grip that allows the instrument to be a potential spear (B).

Dr. Smith will be speaking at the

2011 Pacific Veterinary Confer-

ence in Anaheim on July 1 and 2,

conducting eight CE sessions in-

cluding complications of tooth extraction. Dr. Smith

is in private specialty practice at the Center for Vet-

erinary Dentistry and Oral Surgery in Gaithersburg,

Maryland. He was previously a professor of surgery

and dentistry at Virginia-Maryland Regional College

of Veterinary Medicine from 1988-2004. Dr. Smith

received his veterinary degree from the University of

Pennsylvania in 1982 and completed a residency in

small animal surgery at UC Davis in 1986. He is the

recipient of numerous awards, including the Norden

Distinguished Teacher Award. Dr. Smith is also the

editor of the Journal of Veterinary Dentistry.

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California Veterinary Medical Association | www.cvma.net . . . 47

CV65_3.indb 47 5/3/11 4:06 PM