Complications in Dental Implant Surgery PDF

Dr. Manish K Bhagania BDS, MDS, FICD, FIBCSOMS Clinical Associate Professor Oral and Maxillofacial Surgery Boston University Henry M Goldman School of Dental Medicine  Introduction  Definition and Scope of the problem  Classification of the various complications ...

Dr. Manish K Bhagania BDS, MDS, FICD, FIBCSOMS Clinical Associate Professor Oral and Maxillofacial Surgery Boston University Henry M Goldman School of Dental Medicine  Introduction  Definition and Scope of the problem  Classification of the various complications  Prevention and Management of Surgical Complications  Other Non Surgical Complications  Conclusion  To explore local and systemic factors that may be responsible for complications encountered in implant therapy  To classify various types of complications  To identify strategic areas of prevention  To establish principles that minimize and manage complications that may arise thereof  Endoosseous implants have revolutionized dental treatment.  High survival rates and improved function have validated their use.  Implants enable single-tooth replacement without restoring adjacent teeth  Diagnosis, Assessment, Imaging and Treatment Planning  Issues brought upon by Surgical Procedures  Prosthodontic and/or Restorative Problems  Periodontal or Maintenance Challenges  Medico-legal Considerations  Huge upsurge in number of implants being placed  No more restricted to a specialist (OMS/Perio)  Non availability of training courses (Mostly Industry Driven)  Poor Treatment Planning  Implants being provided in compromised patients and sites  Flawed Success rates causing lack of scientific understanding  Not adhering to guidelines and standard of care  Inadequate Communication (Patient-Dentist-Lab-Vendor) 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) Dent Clin N Am 59 (2015) 1–23 http://dx.doi.org/10.1016/j.cden.2014.09.001  Reversible vs. Irreversible Minor vs. Major Unavoidable vs. Avoidable Reversible Minor complication: Avoidable complication: is a complications: usually self-limiting and complication such as a nerve resolve on their own and usually of short impairment caused by have no associated long- duration, with no placing an implant in the term morbidity (e.g., permanent or lasting mandibular canal, without improper angulation deficits. (e.g., swelling the use of a CBCT scan to upon implant placement and bruising). give the clinician an accurate after the first drill Major complication: representation of the proper osteotomy, which may be more serious nerve location. corrected easily). complication that is Unavoidable complication: is Irreversible longer lasting, a complication that cannot be complications: potentially permanent, avoided or preventable in permanent and cannot with associated most instances and is not be reversed, thus having possible morbidities directly a result of increased severity and (e.g., infection, nerve negligence of the implant consequences (e.g., impairment). clinician. mandible fracture after implant placement).  Assessment and Treatment Planning  Compromised Patients  Compromised Sites  Surgery Related  Immediate  Delayed  Prosthesis Related  Incorrect design  Restorative failure  Patient Related  Maintenance  Habits Immediate Late  Poor Stability  Flap Necrosis  Implant Exposure  Peri-Implantitis  Wrong Position  Loss of Graft  Implant Fracture  Donor/Graft site Infection  Nerve Injury  Oro-Antral Communication  Bleeding  Displacement  Minor bleed is common, major bleeding is uncommon and can be life threatening  Systemic issues relate to medications and coagulopathies  For patients taking warfarin, the overall frequency of persistent bleeding (2%) is low when all dental procedures are considered.  However, when extractions are combined with placement of an implant, the incidence of persistent bleeding increases to 4.8%.  The mechanism of action of these newer medications is different from that of warfarin: they directly inhibit either thrombin (dabigatran) or factor Xa (apixaban and rivaroxaban).  Oral antithrombotic medication, including dual antiplatelet therapy, should not be interrupted for simple dental procedures  Dubois and colleagues reviewed 18 reported cases of life-threatening hemorrhage after implant surgery, most of which occurred when implants were placed in the region between the canines. Eight patients required intubation and 7 needed tracheostomies to ensure patency of the airway. Three of the 18 cases were managed by observation  The cause of bleeding during implant placement in the anterior mandible is perforation of the lingual cortex, resulting in injury to the terminal branches of the sublingual or submental artery.  Retraction of the artery after laceration makes ligation difficult or impossible requiring extraoral surgical approaches  Moderate or severe maxillary bleeding may result from injury to intraosseous vessels lying within the walls of the maxilla.  Criteria:  presence of purulent drainage (either spontaneously or by incision) or fistula in the operative region  pain or tenderness  localized swelling  redness, or fever  Most early infections occur when grafts are used  Bacterial contamination during implant insertion  Fungal Infections and Actinomycotic Infections have also been reported  No standard protocol exists regarding Prophylactic or Post Op ABx  Healing of extraction sites when no socket preservation techniques are used results in the resorption of an average of 1 to 2mm of vertical alveolar bone height and an average of 4 to 5mm of horizontal alveolar bone width.  2/3 of this bone loss occurs during the first 3 months after tooth extraction  There are 3 main sources of blood supply to the alveolar bone around teeth:  periodontal ligament blood vessels  periosteal blood vessels  alveolar bone blood vessels  Bone grafting is frequently used to prevent collapse and to minimize resorption of the thin buccal plate Lang and associates suggest that the survival rate of immediate implants is 97.3% to 99%.  Dimensions of the alveolar ridge can be maintained  Soft tissue preservation is optimal after immediate implant placement  The number of operative interventions required and the treatment time is reduced  Ideal orientation of the implant may be achieved  Eventually may provide optimal restorative esthetics Indications Contraindications  Good oral hygiene  Active infection  Presence of a single failing tooth with good  Lack of bone beyond the apex adjacent dentition  Presence of adequate and harmonious gingival  A close relationship to anatomic vital architecture structures  Adequate bone volume with minimum  Dental history of bruxism dimensions of 3.5 10 mm and without the need parafunctional habits for bone grafting  Lack of stable posterior occlusion  No dental trauma affecting the alveolar bone  Osseous-level dental decay without purulence  Perforation or loss of the labial bony plate after tooth removal  Endodontic failure without periapical infection  Inability to achieve primary stability  A horizontal bone defect is defined as the longest distance in a perpendicular direction from the implant surface to the socket wall.  In 2003, Botticelli and associates introduced the term ”Jumping distance”  It is the horizontal distance between the implant surface and the surrounding bony wall of the socket.  Human and animal studies have shown that, in implant sites with an horizontal defect dimension of 2 mm or less, spontaneous bone regeneration and osseointegration with adequate bone-to-implant contact can occur; however, if the horizontal defect dimension is larger than 2 mm, the use of a barrier membrane with or without membrane supporting bone grafting material is warranted  Thin cortical plate/Un-even crestal ridge/Too large implant  Bone quality and quantity The Effect of Implant Length and Diameter on the  Implant site (anatomic position) Primary Stability in Different Bone Types. J Dent (Tehran). 2013 Sep; 10(5): 449–455.  Implant diameter  Implant length Aim: evaluate the influence of mechanical characteristics of the implant on primary stability in  Surgical Technique different bone types, based on resonance frequency analysis (RFA) Conclusion: In cases of low bone quality, the optimum increase in the implant length and diameter should be taken into account to achieve higher primary stability.  Does the Implant Surgical Technique Affect the  Over size drilling Primary and/or Secondary Stability of Dental Implants? A Systematic Review  Under length drilling Conclusion:  Perforating cortical plate Undersized drilling: weak evidence that it could enhance the primary implant stability in sites of  Changing implant drilling direction poor bone density Osteotome technique: weak evidence that in poor  Wrong implant drilling system bone density could enhance the primary stability Flapless: There is a weak evidence suggesting that could enhance the primary stability  Injury to the IAN can result in partial or complete paresthesia, analgesia, anesthesia, or in rare cases dysesthesia, to the structures it innervates.  The incidence of IAN injury secondary to dental implant surgery is variable, with a range of 0% to 44% in the literature.  The etiology of IAN injury is usually associated with inadequate planning or overzealous implant placement, with injury occurring as a result of either miscalculation of nerve position from the preoperative radiographic assessment or injury via placing implant drills or fixture too apical into the nerve canal. In rare cases, the IAN can be injured from local anesthetic injection (injection injury) or retraction of the gingival flap causing stretching of the mental nerve (terminal branch of the IAN).  In the edentulous/atrophic mandible, the mental foramen may be located at the crest of the alveolar ridge, and it can be at a higher risk of being traumatized from incision and flap elevation  Cone beam computerized tomograms (CBCTs) or conventional computed tomography (CT) scans can be utilized as part of the treatment planning phase to not only plan for implant size, location, and vector of placement, but also to identify and avoid the mandibular canal.  Intraoperatively, utilizing CT-based surgical guides (presurgically fabricated based on CT evaluation during the treatment planning phase with precise CT-based placement of the dental implant with depth control away from IAN) can also protect the IAN.  Other options include taking radiographs step by step during the procedure with either a drill or positioning locator in place to ensure that the drilling has not gone more apical than planned.  If radiographically the IAN canal is violated or it appears that a drill has gone too apical, options include using shorter drills for a shorter implant, aborting the procedure with or without a bone graft  If the radiograph indicates that the canal is violated, clinical assessment can give clues to extent of injury (if any). Violation or injury to the IAN will cause electric shock like pain in even those with good nerve block; the appearance of significant (though transient) bleeding may occur out of osteotomy.  Use of local infiltration as opposed to nerve block can also maintain patient feedback while drilling in the posterior mandible.  Topical dexamethasone has been suggested to reduce inflammation in the site of injury.  If there is witnessed gross injury to the mandibular canal or IAN, then immediate referral to a microsurgery specialist for treatment is indicated  Pharmacotherapy for NP includes a variety of agents  Tricyclic antidepressants drugs, such as amitriptyline, desipramine, and nortriptyline.  Serotonin and norepinephrine reuptake inhibitors, such as duloxetine and venlafaxine  Anticonvulsants drugs, such as gabapentin and pregabalin  Local anesthetics are often used as a diagnostic tool  Topical medications, such as lidocaine or benzocaine, can be helpful in reducing local pain.  degree of perforation dictates treatment  perforation that occurs with the pilot drill is minor: shortening the length of the subsequent osteotomies is enough to avoid significant damage to the underlying membrane.  Larger perforations: treated via internal sinus lifts or placing collagen membrane or infusing rhBMP graft at the apex of the osteotomy.  In the situation of large perforations, abortion of the placement of the implant is required, replaced with collagen membrane placement at the apex of the osteotomy with bone grafting to avoid sinus complications  Nasal floor perforations may be associated with minor nasal bleeding, which is often transient. In both situations, sinus precautions postoperatively, as well as appropriate antibiotic coverage, is indicated.  The advantages:  preservation of the blood supply,  protection of the soft and hard tissues, Tissue Punch  shorter surgical times,  less postoperative pain, and  Increased patient satisfaction.  Published reports indicate that patients who undergo flapless surgical implant procedures experience a significant reduction in postoperative pain and swelling and in the use of analgesics  A major disadvantage of this technique is not being able to fully appreciate the anatomy of the alveolar bone.  This is a blind surgical technique; perforation of the buccal or lingual/palatal cortices may occur without the surgeon’s knowledge, compromising the fixture.  Further, the inability to visualize the crestal bone may result in implants that are too shallow or placed too deep, creating prosthetic problems  Prevention:  CBCT to determine Surgical steps  A virtual surgically planned implant guide can eliminate many of these problems as well as ensure placement of the implant into the presurgically determined ideal position and depth.  Plain dental radiographs immediately following implant placement prior to closure can also help determine whether ideal vertical placement of the implant has been achieved Sanivarapu S, Moogla S, Kuntcham RS, Kolaparthy LK. Implant fractures: Rare but not exceptional. J Indian Soc Periodontol. 2016 Jan-Feb;20(1):6-11.  Removal of the fractured implant (replace the implant and manufacture a new prosthesis), Alteration of the existing prosthesis and maintenance of the osseointegrated fractured part, and Alteration of the fractured implant and remanufacturing of the prosthetic portion.  “Peri-implantitis is a inflammatory process causing destruction of the hard and soft tissue surround the dental implant.”  The etiology is associated with a bacterial biofilm coating the implant. This film has been shown to attach and colonize within minutes to an hour after placement and then exponentially proliferate Clinical Features: Radiographic Features: can be clinically stable Loss of alveolar bone or symptomatic: mobility of implant, purulent or sero- sanguinous drainage, foul odor, gingival bleeding, or rarely, pain. surrounding tissues may appear edematous or tender on examination  Prevention of peri-implantitis is primarily on the patient’s shoulders to maintain excellent oral hygiene. The surgeon, however, needs to educate the patient on hygiene importance and procedure.  Once the endosseous implants have been restored, it is the responsibility of the restorative dentist to ensure that the dental prosthesis is easily cleansable and does not create areas for plaque build-up around the implants.  Minimal bone loss and probing depths of less than 4 mm usually require plaque and calculus removal, polishing of the implant crown, and increased oral hygiene visits annually.  Mild bone loss and probing depths of 4 to 6mmrequire, in addition to increased hygiene visits, chlorhexidine rinses daily or the application of chlorhexidine gels to the affected area.  If probing depths increase beyond 6 mm of significant bone loss (implant still stable), then in addition to hygiene and rinsing, systemic antibiotics focused on gram-negative coverage (metronidazole) is administered for 10 days.  Once any suppuration, edema, and/or infection has resolved, it is reasonable to consider guided tissue regenerative procedures with allogenic bone grafting to restore bone height around the implant.  If the implant is restored, the restoration should be taken out of occlusion to minimize functional loads.  Mobility of implants results in implant failure, and removal is required with possible bone grafting if desired  KEY POINTS  The diagnosis of peri-implantitis benefits from clinical, radiographic, microbiological, and biological information.  Practitioners and patients can use biomarkers to identify risk of disease, disease activity, disease progression, and response to therapy.  Peri-implantitis is a biofilm-induced condition. The microbial composition of periimplantitis lesions is mixed, nonspecific, and less diverse than that of periodontitis but includes Fusobacterium, Prevotella, Porphyromonas, Streptococcus, Campylobacter, and Neisseria species.  Failed implants are often associated with enteric bacteria, spirochetes, and opportunistic bacteria (ie, Staphylococcus aureus).  Protein biomarkers detected in peri-implant crevicular fluid provide insight into the underlying biology of the disease and specificity regarding the stage of the disease. Dent Clin N Am 59 (2015) 179–194  Increase Education  Seek Accreditation  Literature Review Updates  Patient Information  Do Not Rush Treatment  Treat for the Long Term, Not the Short Term  Follow-Up Care  Questions??? : [email protected]