implant complications.pptx

Complications and their management in implant dentistry Contents Classifications Intraoperative complications Postoperative complications Complication prevention Avoiding Complications in oral implantology. Carl E Misch 2 Complication Classification Clavien et al proposed a classification of complic...

Complications and their management in implant dentistry Contents Classifications Intraoperative complications Postoperative complications Complication prevention Avoiding Complications in oral implantology. Carl E Misch 2 Complication Classification Clavien et al proposed a classification of complications, which has subsequently been used in the medical literature for outcome assessment. However, this classification may not be the most practical for the assessment of oral implantology complications. Grade 1: Any deviation from the normal postoperative course that does not require pharmacologic intervention (i.e., pain, swelling) Grade 2: Any deviation from the normal postoperative course that does require pharmacologic intervention (i.e., infection) Grade 3: A deviation that requires surgical intervention (i.e., incision and draining) Grade 4: Life-threatening complication requiring hosptitalization (i.e., sublingual hematoma) Avoiding Complications in oral implantology. Carl E Misch 3 Minor vs. Major A minor complication is self-limiting and usually of short duration, with no permanent or lasting deficits. (e.g., swelling and bruising). A major complication is a more serious complication that is longer lasting, potentially permanent, with associated possible morbidities (e.g., infection, nerve impairment). Avoiding Complications in oral implantology. Carl E Misch 4 Unavoidable vs. Avoidable An avoidable complication is a complication such as a nerve impairment caused by placing an implant in the mandibular canal, without the use of a CBCT scan to give the clinician an accurate representation of the proper nerve location. An unavoidable complication is a complication that cannot be avoided or preventable in most instances and is not directly a result of negligence of the implant clinician.(e.g., nerve impairment secondary to administration of inferior alveolar nerve block). Avoiding Complications in oral implantology. Carl E Misch 5 Reversible vs. Irreversible Reversible complications are complications that usually resolve on their own and have no associated long-term morbidity (e.g., improper angulation upon implant placement after the first drill osteotomy, which may be corrected easily). Irreversible complications are complications that are permanent and cannot be reversed, thus having increased severity and consequences (e.g., mandible fracture after implant placement) Avoiding Complications in oral implantology. Carl E Misch 6 Intraoperative complications Bleeding Infection Nerve injuries Broken burs Malpositioning of implants Overpreparation of Final Drill Aspiration of instruments Cortical plate perforations Injury to adjacent teeth Overheating the Bone Air emphysema Local anesthesia related Avoiding Complications in oral implantology. Carl E Misch 7 Bleeding Bleeding According to Source Arterial hemorrhage: bright red, spurting/pulsatile Venous hemorrhage: dark red, continuous Capillary hemorrhage: bright red, continuous Primary hemorrhage: This type of bleeding occurs during surgery and is usually the result of the incision, retraction, or preparation of the soft or hard tissue Reactionary hemorrhage: occur within hours after surgery. most likely occurs in patients who exhibit systemic bleeding issues, are on anticoagulant therapy, or experience postoperative trauma to the surgical area that disturbs the clot Secondary hemorrhage: This type of bleeding occurs 7–10 days after surgery and is most likely the result of an infection. Avoiding Complications in oral implantology. Carl E Misch 8 Factors Contributing to Intraoperative Bleeding Hypertension Medications- anticoagulants, antiplatelet drugs, nsaids Systemic bleeding disorders- hemophillia, von willebrands, factor deficiencies. Liver Disorders. Liver disease (e.g., cirrhosis, acute liver failure) is associated with many significant abnormalities of the coagulation system Avoiding Complications in oral implantology. Carl E Misch 9 Techniques to Decrease and Control Bleeding Mechanical Methods Positional Changes- Repositioning the patient to an upright position (head above the heart) will not stop the bleeding; however, it will significantly decrease the hemorrhage (studies have shown a decrease up to 38%) Direct Pressure- Pressure or compression directly on the blood vessel will allow for platelet aggregation and initiation of the coagulation cascade. Pressure may be applied manually or by the patient biting forcefully on a gauze dressing. Pressure should be maintained for at least 3 to 5 minutes to allow the formation of a blood clot. Avoiding Complications in oral implantology. Carl E Misch 10 Suturing- The suture is placed by entering the tissue at least 4 mm from the bleeding vessel, 3 mm below the vessel, and 4 mm exiting the tissue. This will ligate or occlude the vessel as long as it is placed proximal to the bleeding area. A figure-eight suture technique is ideally utilized Clamped Vessel With Hemostat Forceps- When local measures are not successful in controlling bleeding, a hemostat may be utilized to clamp the blood vessel. Thermal Techniques- electrocautery, Lasers Pharmacologic Techniques- Epinephrine. When locally placed, epinephrine will reduce bleeding, slow the absorption of the local anesthetic, and prolong the anesthetic and analgesic effect Avoiding Complications in oral implantology. Carl E Misch 11 Tranexamic Acid SolutionTranexamic acid 4.8% is an antifibrinolytic oral rinse that facilitates clot formation by inhibiting the activation of plasminogen to plasmin Topical Hemostatic AgentsAbsorbable topical hemostatic agents are used when conventional methods of hemostasis are ineffective. These agents may be placed directly into the bleeding site to decrease bleeding during the procedure or during the postoperative interval (collagen, gelatin, cellulose, chitosan based, beeswax) Avoiding Complications in oral implantology. Carl E Misch 12 Infection Factors Associated With Increased Risk of Infection for Dental Implant Procedures Systemic Factors Diabetes Long-term corticosteroid use Smoking Immunocompromised systemic disorders Malnutrition, obesity Elderly population Local Factors Use/type of grafting material (autogenous, allograft, alloplast) Periodontal disease Tissue inflammation Odontogenic infections Ill-fitting provisional prosthesis Incision line opening Inadequate hygiene Surgical Factors Poor aseptic technique Skill/experience of the surgeon Increased duration of surgery Wound contamination during surgery Foreign body (implant) Avoiding Complications in oral implantology. Carl E Misch 13 Signs of Infection Vital Signs Temperature: >101°F (38°C) (normal: 98.6°F [37 °C]) Pulse Rate: >100 beats/min (normal: 60–100 beats/min) Blood Pressure: Systolic will be elevated if there is pain/anxiety Respirations: >18 breaths/min (normal: 14–16 breaths/min) Mild Infection. Normal vital signs with slight elevation of temperature. Usually associated with one of the following: Fatigue: extreme tiredness Malaise: a general feeling of discomfort, illness, or uneasiness Lethargy: lack of energy or enthusiasm Severe Infection. Elevated pulse, blood pressure, and respirations along with temperature and any of the following- Trismus, Lymphadenopathy, dysphagia Avoiding Complications in oral implantology. Carl E Misch 14 Prevention and Treatment of Infection Antibiotic therapy utilized in implant dentistry may be classified as either prophylactic (to prevent infection) or therapeutic (to treat infection). Prophylactic Antibiotics- Amoxicillin is the drug of choice. If the patient is allergic, alternative drugs are: Cephalexin (nonanaphylactic allergy to penicillin) Clindamycin (anaphylactic allergy to penicillin) The recommended treatment for intraoral infections associated with implant therapy include the following: 1. Surgical drainage- This procedure includes the incision of the abscess or cellulitis, which results in the removal of the accumulated pus and bacteria from the underlying tissue. Avoiding Complications in oral implantology. Carl E Misch 15 2. Systemic antibiotics- Amoxicillin (500 mg)/two immediately, then one tablet three times daily for 1 week; or if penicillin allergy exists Clindamycin (300 mg)/two immediately, then one tablet three times daily for 1 week. Use of Chlorhexidine in Oral Implantology Patient presurgical rinse. It can be used in the aseptic protocol before surgery for reduction of bacterial load Surface antiseptic. It can be used in the intra- and extraoral scrub of patient, scrubbing of hands before gowns and gloves Postsurgical rinse. Patient should rinse twice a day until incision line closure Periimplant maintenance on daily basis. Treatment of postoperative infections. Avoiding Complications in oral implantology. Carl E Misch 16 Sterile Technique Avoiding Complications in oral implantology. Carl E Misch 17 Nerve injuries Etiology Administration of Local Anesthesia- needle, hematoma, toxicity Soft Tissue Reflection: may occur during the reflection, retraction, or suturing of the soft tissue. Implant Drill Trauma- Drill Encroachment, partial penetration, transection Anesthesia Total Loss of Feeling or Sensation Dysesthesia Abnormal sensation that is unpleasant Paresthesia Abnormal sensation that is not unpleasant Hypoesthesia Decreased sensitivity to stimulation Avoiding Complications in oral implantology. Carl E Misch 18 Management 1. Nerve Impairment at Time of Surgery During surgery, if known traction or compression of the nerve trunk has occurred, the topical application of Dexamethasone may be used to minimize deficits. Upon removal of an encroaching implant on the mandibular canal, 1–2 mL of the intravenous form of Dexamethasone (4 mg/mL) is topically applied). This direct steroid application will reduce neural inflammation and may enhance recovery from neurosensory deficits. Studies have shown no morbidity associated with the topical application of glucocorticoids at the injury site and postsurgical recovery has also been shown to improve significantly.. Avoiding Complications in oral implantology. Carl E Misch 21 Nerve impairment post surgically Avoiding Complications in oral implantology. Carl E Misch 22 Bur “Stuck” in Bone During Osteotomy Often in hard bone (≈D1–D2 bone), if the handpiece is stopped with the surgical drill in the bone, it may be difficult to remove out of the osteotomy Prevention: in dense bone small (minimal) increments of bone should be removed at a time, which will result in less stress to the bone and will allow for ease of widening the osteotomy. Also, by using intermediate burs (more burs close in diameter), smaller amounts of bone are removed at a given time, decreasing the possibility of burs being lodged in the bone Treatment: If a bone drill becomes lodged in the bone during preparation, the hand piece should not be wiggled back and forth to disengage the drill. This may increase the size of the bone preparation, cause injury and necrosis to the bone, or separate the drill above or below the bone. Instead, the drill is disengaged from the handpiece and gently rotated counterclockwise with forceps or rongeurs. Avoiding Complications in oral implantology. Carl E Misch 23 Over-preparation of Final Drill Etiology- The final drill is the most critical surgical step in the osteotomy preparation. The bone surrounding this drill will be in direct contact with the implant. When the final drill preparation is not precise, the implant-bone region may be irregular with gaps that may decrease initial stability and lead to early implant failure Prevention A constant pressure and angulation is used with the final drill to ensure that a precise, round osteotomy is prepared. The most important factor is the use of the final drill only once to avoid over preparation, most importantly in less dense bone Treatment If overpreparation of the osteotomy site occurs, clinical evaluation should be completed to determine if mobility of the implant exists. Remove Implant, Place Wider Implant. Remove Implant, Graft, Let Heal. Avoiding Complications in oral implantology. Carl E Misch 24 Facial Dehiscence After Implant Placement Etiology Bony defects at the crest after implant placement will usually result in lack of available bone width at the ridge level Prevention All ridges should be modified to obtain a division A bone (e.g., >6 mm width and >12 mm of bone height) before osteotomy initiation. After implant placement, 1.5 mm of facial bone should be present or the area should be grafted. Treatment After implant placement, if there exists less than 1.5 mm of bone on the facial aspect of the ridge, the site may be grafted with autogenous bone (ideally). The autogenous bone may be obtained from fragments gathered from the flutes of the surgical drills during the osteotomy preparation Avoiding Complications in oral implantology. Carl E Misch 25 Loss of Facial Plate When Placing an Implant Etiology: When compromised width of bone exists, the trauma of the osteotomy or the placement of the implant may fracture or “pop off” the buccal plate. This is most likely the result of the buccal plate being thinner than the lingual plate. Prevention- The osteotomy preparation should be in one plane, and care should be exercised to not deviate from the original angulation. Avoiding Complications in oral implantology. Carl E Misch 26 Treatment Loss of Entire Buccal Plate or if mobility of the implant exists, the ideal treatment should include grafting then allowing for sufficient healing before implant placement. Partial Buccal Plate Still Intact and If no mobility of the implant is present the facial area can be grafted, ideally with autogenous bone from the osteotomy site Avoiding Complications in oral implantology. Carl E Misch 27 Overheating the Bone Etiology The amount of heat produced in the bone is directly related to the amount of bone removed by each drill. Lack of gradual increase in drill diameter. Prevention- Intermediate Drills. Gradual increases in drill diameter reduce the amount of pressure and heat transmitted to the bone. Copious Amounts of Saline. Bone Dance. When preparing the osteotomy, small increments of bone should be removed, and by using the up-and-down motion of the drill, irrigation may enter the osteotomy site easier Use of Sharp, New Drills Avoiding Complications in oral implantology. Carl E Misch 28 Drill Speed. Osteotomy preparation at higher speeds with sharp drills elicits less risk of osseous damage and a decreased amount of devitalized zone adjacent to the implant. Treatment If known excess heat generation occurs during implant placement, ideally the implant should be removed, regional acceleratory phenomenon (RAP) initiated, and the site grafted for future implant placement. If bone width is available after sufficient RAP is completed, a wider implant may be placed Avoiding Complications in oral implantology. Carl E Misch 29 Swallowing/Aspiration of Implant Components Etiology Because of the small size of abutments, screws, drivers, and other implant components, a significant risk for aspiration exists. This may occur during any dental implant procedure, including the surgical and prosthetic phases. There are two possibilities: the patient may swallow the foreign object into the stomach or aspirate the foreign material into the lungs. Avoiding Complications in oral implantology. Carl E Misch 30 Swallow. If the object is swallowed, usually the patient will be asymptomatic. However, depending on the shape and size of the object, it may need to be removed because of the complication of blockage or not passing through the gastrointestinal system. Aspiration. The object may end up in the lungs, in which case the patient will be symptomatic. The patient will exhibit signs of coughing, wheezing, hoarseness, choking, stridor, or cyanosis. Prevention- Floss ligatures to all possible implant components Use throat packs (4 × 4 gauze) or pharyngeal screens Highvacuum function Avoiding Complications in oral implantology. Carl E Misch 31 Treatment If an instrument is lost in the mouth, the patient should first be instructed to not sit straight up because this will ensure the swallowing or aspiration of the instrument. The patient should turn to the side and attempt to “cough” the instrument up. If the instrument has been swallowed into the stomach, usually the patient will exhibit no symptoms. If the patient has aspirated the instrument, this will most likely be accompanied with coughing, wheezing, pain, and cyanosis. This may be life-threatening and should be treated accordingly as a medical emergency. In all swallowing/aspiration situations, the patient should be referred to their physician or emergency room for an immediate chest xray. If the instrument has been aspirated, it is usually located in the right bronchus because the right main bronchus has a more acute angle than the left. Rigid bronchoscopy is usually used for the removal of the instrument under general anesthesia Avoiding Complications in oral implantology. Carl E Misch 32 Air Emphysema Etiology: Because of the attachment apparatus difference between implants and teeth, air extruded into the sulcular area around implants may lead to air emphysema. The two most common ways for this to occur is the use of an airdriven handpiece or an air-water syringe in which air is forced into the sulcular area. Symptoms will include swelling that increases over time with a “crackling” feeling with pain. Crepitus to palpation will confirm the diagnosis of air emphysema. The patient will usually be apprehensive with a feeling of difficulty in breathing Avoiding Complications in oral implantology. Carl E Misch 33 Prevention: When placing implants, modifying abutments with the mouth, or removing bone around an implant body, an electric handpiece should always be used (i.e., never use a air-driven handpiece). Additionally, an air-water syringe should never be used to place air into the sulcular area parallel to the long axis of the implant. Treatment- Patients with significant emphysema should be monitored closely prior to discharge for respiratory or cardiac distress. Treatment should include supportive therapy with heat and analgesics. Antibiotic therapy should always be given because infection may result from bacteria being induced into the fascial spaces with resultant cellulitis or necrotizing fascitis. Resolution usually occurs in 4 to 7 days with minimal morbidity. Avoiding Complications in oral implantology. Carl E Misch 34 Insufficient Implant–Root Apex Distance Etiology: Implants placed too close to an adjacent tooth root are usually the result of poor treatment planning (inadequate space), poor surgical technique (improper angulation), or placement of too wide of an implant body. This may occur when there are root dilacerations of an adjacent tooth Complications- Damage to Adjacent Periodontal Ligament, Loss of Implant (Implants that are placed too close to an adjacent tooth may fail due to infection or bone resorption), Loss of Tooth (the adjacent tooth may be irreversibly traumatized and may be lost to a fracture or to internal or external resorption) Prevention- Ideal Position. The ideal position is to maintain at least 1.5 mm from the adjacent tooth root or tooth structure Avoiding Complications in oral implantology. Carl E Misch 35 Proper Treatment Planning, Use of Study Casts, 3D imaging, Treatment Initial Placement. If there is insufficient space between an implant and a natural tooth, the implant should be removed and repositioned, especially if the adjacent tooth is symptomatic. If space is compromised (less than 6mm)the roots should be repositioned via orthodontics or treatment plan changed to a different type of prosthesis. Past Placement. If an implant has been restored and root approximation (less than 1.5mm) exists, the tooth/implant should be monitored on a regular basis and the patient informed of the possible morbidity. If symptomatic or radiographic pathology is present, the implant should be removed and repositioned along with vitality testing of the tooth Avoiding Complications in oral implantology. Carl E Misch 36 Lack of Implant–Coronal Distance Etiology: occurs most likely from poor initial osteotomy positioning, poor treatment planning, or the use of too large of an implant body Complications- Interproximal Bone Loss, Compromised Emergence Profile, Hygiene Difficulties, Reduced Papilla Height. Prevention- Treatment Planning, Surgical Adjuvants.(templates and guides) Avoiding Complications in oral implantology. Carl E Misch 37 Treatment Initial Placement. If the position of the implant is less than 1.0 mm from the adjacent clinical crown, removal and reposition of the implant should be completed. If the implant is positioned 1.1 to 1.5 mm from adjacent tooth, removal or modification (enameloplasty) of the adjacent tooth may be completed, as long as irreversible damage to the tooth is not done. Past Placement. the tooth/implant should be monitored. If symptomatic, the implant should be removed and repositioned along with vitality testing of the tooth. Avoiding Complications in oral implantology. Carl E Misch 38 Inability to Obtain Mandibular Block In edentulous mandibles or patients being treated with sedation, this may be difficult, and alternative anesthesia techniques are warranted require the use of reference points (occlusal plane), which are not present in edentulous patients. Additionally, many dental implant patients are sedated, which results in difficulty for the patient to open fully for the injection. Prevention The implant clinician must understand and utilize profound, alternative anesthesia techniques such as the Akinosi technique. Avoiding Complications in oral implantology. Carl E Misch 39 Post operative complications Swelling Ecchymosis Trismus Post surgical pain Post operative bleeding Post surgical nausea Titanium Allergy/Hypersensitivity Fractured Mandible After Implant Placement Partial Cover Screw Exposure Fractured Implant Displacement or Migration Complications Avoiding Complications in oral implantology. Carl E Misch 42 Post-operative Swelling Two variables determine the extent of edema: (1) the amount of tissue injury is proportional to the amount of edema; (2) the more loose the connective tissue at the surgery site, the more edema is most likely to be present Prevention good surgical technique must be used with minimal tissue trauma. excessive retraction, and long surgical duration, which will all contribute to increased inflammation after surgery. Avoiding Complications in oral implantology. Carl E Misch 43 Postoperative prophylactic medications such as ibuprofen (nonsteroidal antiinflammatory drugs [NSAIDs]) and glucocorticosteroids (steroids) are utilized as prophylactic medications, which counteract the negative effects of the edema cascade Cryotherapy- Cold dressings (ice packs) should be applied extraorally (not directly on skin: place a layer of dry cloth between ice and skin) over the surgical site for 20 minutes on/20 minutes off for the first 24– 36 hours Treatment Swelling is self-limiting and, once it occurs, it is usually difficult to treat (time-dependent). The above mentioned medications/therapy (Decadron, NSAIDs, cryotherapy) will help to reduce postoperative inflammation Avoiding Complications in oral implantology. Carl E Misch 44 Ecchymosis (Bruising) Ecchymosis is subcutaneous extravasation of blood within the tissues, which results in discoloration of the skin from the seepage of blood in the tissues. Moderate bruising should be expected after dental implant surgery, especially after longer, more invasive surgeries. Female and elderly patients are more susceptible to bruising Prevention: Unfortunately, even with gentle handling of tissues and good surgical technique, ecchymosis may be unavoidable. To minimize ecchymosis, avoid postoperative aspirin, herbal remedies, and food supplements that may increase bleeding Avoiding Complications in oral implantology. Carl E Misch 45 Treatment Ecchymosis is self-limiting and usually resolves without treatment. However, the patient may treat the ecchymosis in the following ways: Rest/avoid strenuous activity: promotes tissue healing and decreases inflammation. Elevation: helps decrease inflammation, facilitates proper venous return, and improves circulation to the site. Analgesics: helps reduce pain associated with the onset of ecchymosis. Sun exposure: inform patient to avoid sun exposure to the area of bruising as excessive sunlight may cause permanent discoloration. Avoiding Complications in oral implantology. Carl E Misch 46 Trismus Etiology: The most likely etiologic factor is local anesthetic, secondary to an inferior alveolar nerve block that penetrates the medial pterygoid muscle. Also, complicated or prolonged surgical procedures that require fullthickness mucoperiosteal flaps with resultant edema can lead to trismus Prevention- When placing implants, especially in the posterior region, care should be taken to minimize excessive opening of the patient to where spasm of the muscles of mastication would result. Bite blocks, short duration treatment, and sedation may decrease the possibility of trismus complications. Treatment Usually trismus will resolve with time; however, patients should maintain a soft diet and minimize overactivity. Additional treatment includes the use of physical therapy, passive range of motion exercises, splint therapy, and medications such as NSAIDs, muscle relaxants, and steroids (Decadron). Avoiding Complications in oral implantology. Carl E Misch 47 Postsurgical Pain Prevention- 1. Good surgical technique 2. Surgery duration not to exceed patient's tolerance 3. Postoperative long-acting anesthetics 4. Adequate postoperative pain control and instructions 5. Limitation of patient activities post-operatively Control of Postoperative Surgical Pain. 1. The first step is to maximize the use of NSAIDs (acetaminophen, ibuprofen) for mild to moderate pain. Adjuvant medications such as glucocorticoids and cryotherapy are often suggested. 2. When moderate pain is expected or persists, an opioid (hydrocodone, codeine) should be added to the NSAID. Glucocorticoids and cryotherapy are encouraged. 3. Moderate to severe pain that is expected or persists should be treated by increasing the dosage of the opioid. Glucocorticoids and cryotherapy are of particular benefit when not contraindicated. Avoiding Complications in oral implantology. Carl E Misch 48 Post-surgical bleeding Patients should be cautioned on the potential for bleeding during the first 24 hours Recommendations should be given to minimize wearing an interim prosthesis because this may result in increased bleeding. For significant or prolonged bleeding, the patient should be instructed to contact the doctor. The patient should also be instructed not to use a straw when drinking fluids because this may create a negative pressure and increase bleeding. Also, spitting and vigorous rinsing may open the surgical wound and cause bleeding Avoiding Complications in oral implantology. Carl E Misch 49 Patients should be instructed to limit their activities for a minimum of 24 hours depending on the extent of the surgery. The head should be elevated as much as possible during the daytime hours and the use of two pillows (i.e., elevate head) during sleeping will reduce secondary bleeding episodes. Avoiding Complications in oral implantology. Carl E Misch 50 Nausea After Surgery The etiology of nausea after surgery may be a direct result from prophylactic medications (Augmentin, Clindamycin) or the swallowing of excessive amounts of blood, especially after longer procedures. Prevention-. Nausea can be reduced by preceding each pain pill with a small amount of soft food, and taking the medication with a large volume of water. Additionally, minimizing the swallowing of excessive amounts of blood will reduce the possibility that the blood will irritate the stomach mucosa (effective suctioning) Treatment If nausea is extensive after surgery, OTC antiemetics may be used or prescription medications (e.g., ondansetron [Zofran] 4-mg sublingual tablets) may be prescribed Avoiding Complications in oral implantology. Carl E Misch 51 Titanium Allergy/Hypersensitivity Etiology- Titanium alloy dental implants have been shown to contain many “impurities” that may trigger type IV hypersensitivity reactions Prevention- Thorough medical history involving any past history of titanium hypersensitivity Treatment When titanium hypersensitivity is suspected, the implants should be removed and the patient should be referred to their physician for appropriate testing Avoiding Complications in oral implantology. Carl E Misch 52 Fractured Mandible After Implant Placement Etiology Fractured mandibles most likely occur from attempting to place implants in patients with severely resorbed ridges, Patients who are predisposed to fractures include those with highly excessive occlusal forces, or with division C−w and D mandibles Additional causes of mandibular fractures include placing implants that are too wide or too long, which compromises the host bone and requires excessive tightening of implants. Late (after surgery) mandibular fractures most likely are caused by an increased stress at the implant site. Repeated functional forces placed on the implant eventually lead to the fracture of the bone Avoiding Complications in oral implantology. Carl E Misch 53 Prevention The prevention of mandibular fractures includes proper treatment planning and diagnosis, which involves the contraindication of implants placed in division D mandibles. Division D patients should be referred for possible iliac crest grafting. Treatment The treatment of a fractured mandible after implant placement is referral to an oral and maxillofacial surgeon for definitive care and possible removal of the offending implants, along with reduction and stabilization of the mandible Avoiding Complications in oral implantology. Carl E Misch 54 Partial Cover Screw Exposure Etiology Incision line opening Excess tension on the incision line Thin tissue (thin biotype) Interim prosthesis pressure Immediate implant placement Implant design—high surgical cover screw Prevention To prevent premature opening, tension should be released from the incision line. This will allow for tension-free closure and minimal pressure on the incision line. The interim prosthesis should be adjusted to have no direct contact on the surgical site Treatment The implant should be uncovered (tissue punch bur) and the smallest permucosal extension (in height) should be used. Ideally, the permucosal extension should be 1 mm above the tissue height. No attempt should be made to resuture and obtain primary closure. The patient should be instructed on proper hygiene to include gentle brushing of the abutment along with the use of chlorhexidine Avoiding Complications in oral implantology. Carl E Misch 55 Fractured Implant Etiology Cantilevers, angled loads, and parafunction increase the risk of fracture. Typical mechanical failures are due to either static loads or fatigue loads. Static load (i.e., one load cycle) failures cause the stress in the material to exceed its ultimate strength after one load application. Fatigue load failures occur if the material is subjected to lower loads but repeated cycles of that load Avoiding Complications in oral implantology. Carl E Misch 56 Prevention: a titanium alloy implant should ideally be used. Parafunctional habits should be addressed with occlusal guards, and an ideal occlusal scheme. Treatment: The ideal treatment for a fractured implant includes the removal and possible replacement of the implant. Alternative treatments include modification of the prosthesis to not include the implant and possible modification of the fractured implant (cementable abutment). Avoiding Complications in oral implantology. Carl E Misch 57 Displacement of Implants: Maxilla The timing of implant displacement into the maxillary sinus proper has been shown to range from the time of surgery to 10 years after prosthetic rehabilitation. When implants are determined to be displaced into the maxillary sinus, immediate evaluation and removal should be rendered. If left untreated, the displaced implants may become calcified (antrolith) or migrate into adjacent anatomic areas. Avoiding Complications in oral implantology. Carl E Misch 58 Maxillary Sinus. All case reports discussing the migration of implants (either early or late migration) find that they originate in the maxillary sinus because of its anatomic location with respect to the maxillary posterior region. After displacement into the maxillary sinus, the dental implants have been reported to migrate to various anatomic areas The physiologic action of the maxillary sinus will transport the dental implant into the ostium area, most likely blocking the area and causing nonpatency. Nonpatency of the maxillary ostium will lead to infection or cause the implant to erode through the ostium to other anatomic areas Avoiding Complications in oral implantology. Carl E Misch 59 Nasal Cavity. Dental implants may migrate from the maxillary sinus into the nasal cavity via extrusion through the ostium or erosion through the medial wall of the sinus (lateral wall of the nasal cavity). Ethmoid Sinus. Dental implants may migrate to the ethmoid sinus via the ostium or erode through the superior wall of the sinus Avoiding Complications in oral implantology. Carl E Misch 60 Orbital Area. The floor of the orbit coincides with the roof (superior) wall of the maxillary sinus. Implants may migrate from the maxillary sinus into the inferior wall of the orbit (superior wall of maxillary sinus) Avoiding Complications in oral implantology. Carl E Misch 61 Etiology (early- at the time of surgery) Poor Bone Quality. Because of the poor bone quality, the bone lacks density and strength and cannot maintain rigid fixation of the implant Poor Surgical Technique. Because of the poor bone quality, if the osteotomy is prepared with a conventional drill sequence (e.g., routine, standard manufacturer's protocol), overpreparation of the osteotomy site will result. Because of the overpreparation, there will be insufficient bone at the crestal level to maintain rigid fixation and migration may occur. Immediate Implant Placement. This is most critical in the first molar area, where the defect from the extraction results in minimal bone to maintain stability of the implant. Avoiding Complications in oral implantology. Carl E Misch 62 Etiology: Late (After Surgery) Migration Negative Pressure. When initial fixation of the implant is absent, because of the compromised bone implant contact (BIC), changes in intrasinus and nasal air pressure may produce a suction effect, causing a negative pressure. This may result in the displacement of the implant into the maxillary sinus Autoimmune Reaction. Many authors have discussed autoimmune reactions with the dental implant, which result in bone loss around the implant, loss of integration, and intrusion into the maxillary sinus Occlusal Overloading. Because of the poor bone quality in the posterior maxilla, excessive occlusal force will result in bone loss or loss of fixation of the implant. Peri-Implantitis. If peri-implantitis around a maxillary posterior implant is left untreated, loss of fixation may result, which will lead to insufficient fixation. Avoiding Complications in oral implantology. Carl E Misch 63 Prevention To prevent displacement and migration of implants into the maxillary sinus, ideal treatment planning along with surgical technique should be adhered to. A comprehensive preoperative evaluation of the posterior maxilla should be completed and the inherent unfavorable anatomic and possible pathologic conditions should be addressed when treatment planning in this area Avoiding Complications in oral implantology. Carl E Misch 64 Treatment Treatment of migrated or displaced implants includes the immediate removal, which usually necessitates referral to an oral and maxillofacial surgeon (OMFS) or otolaryngologist (ENT). The most common approaches for removal of implants include the traditional Caldwell-Luc procedure, intraoral approach, or a transnasal approach with functional endoscopic sinus surgery Avoiding Complications in oral implantology. Carl E Misch 65 Conclusion: Complications Prevention Increase Education: Implant dentists must have a firm and deep understanding about a wide spectrum of subjects ranging from CBCT interpretation and diagnosis, treatment planning, hard and soft tissue management, prosthetic design, esthetic presentation, pharmacology, surgical principles, and numerous other subjects. Seek Accreditation: It is also highly recommended for clinicians to test themselves by seeking accreditation with the various implant boards and groups. This higher level of accreditation is vital for the implant dentist to perform because it helps to build a deeper understanding and greater mastery of the various aspects of oral implantology Literature Review Updates: Another way for the prevention of implant complications is to become familiar with the process of literature review. A good piece of advice forAvoiding the avoidance of implantology. complications is to “not be the first, Complications in oral Carl E 66 Misch in the field nor the last” to the latest trends or ideas Patient Information: The patient should be informed of the advantages, disadvantages, risks, and potential complications regarding each treatment option Do Not Rush Treatment: During treatment, the clinician can avoid substantial complications by avoiding the urge to rush through the proper sequence and timelines for implant dentistry Treat for the Long Term, Not the Short Term Follow-Up Care: The last aspect of complication prevention is a policy of strong follow-up care. Keeping communication open with the patient through all the phases of treatment is vital to staying on top of any potential complication issues. Avoiding Complications in oral implantology. Carl E Misch 67 Thank you…. 68