Dental Implant Complications PDF

DENTAL IMPLANTCOMPLICATIONS DR. Claudina E. Lagman Introduction Implantology is an ever growing field. Nevertheless, it has, as every surgical procedure, several complications that can occur and that must be known in order to prevent or solve them. It is mandatory to classify all those clinical comp...

DENTAL IMPLANTCOMPLICATIONS DR. Claudina E. Lagman Introduction Implantology is an ever growing field. Nevertheless, it has, as every surgical procedure, several complications that can occur and that must be known in order to prevent or solve them. It is mandatory to classify all those clinical complications that can arise. Accidents are events that occur during surgery Accidents always happen during surgical procedures. Complications appear lately, once surgery is already performed. There are two kinds of complications, depending on the time they emerge: early and late. Early-stage complications appear in the immediate postoperative period and interfere with healing, Late-stage complications arise during the process of osseointegration. Failures occur when the professional and/or the patient do not obtain the desirable results Iatrogenic acts are regarded as accidents, complications or failures caused by a deficient praxis of the professional (Annibali et al, 2009) Local complications in dental implant surgery. Infection Edema Ecchymoses and haematomas Emphysema Bleeding Flap dehiscence Sensory disorders Perforation of the mucoperiosteum Maxillary sinusitis Mandibular fractures Failed osseointegration Bony defects Periapical implant lesion (Misch and Wang,2008) CLASSIFICATION (Carranza) Surgical complications Biologic complications Technical or mechanical complications Esthetic and phonetic complications Surgical complications Hemorrhage and hematoma Neurosensory disturbances Damage to adjacent teeth Biologic complications Inflammation Dehiscence and recession Periimplantitis and bone loss Implant loss or failure Screw loosening and fracture Implant fracture Fracture of restorative Technical complications materials Esthetic complications Esthetic and Phonetic complications phonetic complications Bleeding Common accident as a consequence of local-anatomical or systemic causes. Causes of bleeding: lesions in any sublingual, lingual, perimandibular, or submaxillary artery Surgeries in the lower and anterior area of totally edentulous patients who have a deficit in the quality and quantity of bone. More prone patients fall in the following category: Group 2 of medical-systemic risk: q Irradiated patients (radiotherapy), q Patients with coagulation disorders (anticoagulated patients or those with haemostatic disorders) q Severe smokers (Buser et al., 2000) Group I includes high risk patients: q Patients with serious systemic diseases (rheumatoid arthritis, osteomalacia, imperfect osteogenesis), q Immunodepressed (HIV, immunosupresory treatments), q Drug addicts (alcohol, etc.), q Unreliable patients (mental or psychological disorders). Elderly - probability of comorbidity is higher and mandatory to know their medical history. Therapeutic options in these patients comprise two approaches: Decrease or eliminate the anticoagulant therapy once patient and physician have assessed risks and benefits. Invasive treatments can be performed ( Bacci et al., 2010): q International Normalized Ratio (INR) are > 4, and q Adequate hemostatic measures are followed and, q Use atraumatic surgery techniques; Treatment: local intraoperative or postoperative measures Local hemostasis (suture, compression, the use of hemostatic microfibrilar collagen gauzes, oxidized cellulose, reabsorbable fibrin, or mouth rinsing with 4,8% of tranexamic acid) Precautions to be taken: Strongly recommended to carry out an exhaustive tomography study of the anatomy of mandible and maxilla. Edema Swelling - more noticeable 24 hours after performing surgery Causes: q Wide flaps, q Bone regenerating techniques, and q surgery time Leads to trismus, lack of hygiene in the wound and discomfort to the patient. Decreases with time, and can easily vanish after a few days. Management Careful management of tissues cold pack Non-steroid antiinflammatory drugs corticosteroids Hemorrhage/ Ecchymosis Severe bleeding and the formation of massive hematomas in the floor of the mouth are the result of an arterial trauma. Several types of hemorrhagic patches can develop as a result of injury: Petechiae (10 mm). Ecchymosis are the result of an intermental surgery procedure. A schema(c representa(on of the arterial anatomy in the floor of the mouth (Kalpidis & Setayesh, 2004). q Swelling and elevation of floor of the mouth q Increase in tongue size q Difficulty in swallowing or speech q Pulsating or profuse bleeding from the floor of the mouth or the osteotomy site Treatment of a hemorrhage at an implant osteotomy site (Park & Wang, 2005) Bleeding site during implant osteotomy Arteries Treatments Posterior mandible Mylohyoid Finger pressure at the site Middle lingual of mandible Submental Surgical ligation of facial and lingual arteries Anterior lingual of mandible Terminal branch of sublingual or submental Compression, vasoconstriction, cauterization, or ligation Invading the mandibular canal Inferior alveolar artery Bone graft The blood supply of the maxillary sinus is derived from the infraorbital artery, the greater palatine artery and the posterior superior alveolar artery (Chanavaz, 1990; Uchida et al., 1998a). Bleeding during sinus augmentation is rare because the main arteries are not within the surgical area. Emphysema Rare complication, though it can lead to severe consequences (McKenzie & Rosenberg, 2009). Causes Inadvertent insufflation propulsion of air into tissues under skin or mucous membranes, Air from a high-speed handpiece, air/water syringe, an air polishing unit or an air abrasive device can be projected into a sulcus, surgical wound, or a laceration in the mouth (Liebenberg & Crawford, 1997) Neurosensory disturbances Nerve lesions are both an intraoperative accident and a postoperative complication that can affect the infra-orbital nerve, the inferior alveolar nerve, or its mental branch and the lingual nerve. These complications have a low incidence (reported between 0%-44%) (Misch & Resnik, 2010) Several implants in contact to the Inferior Alveolar nerve in patients with postoperative paresthesia. Causes INDIRECT Postsurgical intra-alveolar edema or hematomas- produce a temporary pressure increase, especially inside the mandibular canal DIRECT Compression, stretch, cut, overheating, and accidental puncture (Annibali et al., 2009) Poor flap design, Traumatic flap reflection, Accidental intraneural injection, Traction on the mental nerve in an elevated flap, Penetration of the osteotomy preparation Compression of the implant body into the canal (Misch & Wang, 2008). The nerve injury may cause one of the following conditions: Parasthesia (numb feeling), Hypoesthesia (reduced feeling), hyperesthesia (increased sensitivity), Dysthesia (painful sensation), or Anesthesia (complete loss of feeling) of the teeth, the lower lip, or the surrounding skin and mucosa (Greenstein & Tarnow, 2006 as cited in Sharawy & Misch, 1999). Neurapraxia: there is no loss of continuity of the nerve; it has been stretched or undergone blunt trauma; the parasthesia will subside, and feeling will return in days to weeks. Axonotmesis: nerve damaged but not severed; feeling returns within 2 to 6 months. Neurotmesis: severed nerve; poor prognosis for resolution of parasthesia. Sharp needle test( tingle or painful) Shortest test between indentation Mapping area of altered feeling Blunt cotton swab test( tingle or painfulor none) Temperatures test( cold, warmth)optional Pulp testing teeth Recommendations to avoid nerve injuries during implant placement (Worthington,2004) Be sure to include nerve injury as an item in the informed consent document. Measure the radiograph with care. Apply the correct magnification factor. Consider the bony crestal anatomy: Is the buccolingual position of the crestal peak of bone influencing the measurement of available bone? Consider the buccolingual position of the nerve canal. Use coronal true-size tomograms where needed. Allow a 1 to 2 mm safety zone. Use a drill guard. Take care with countersinking not to lose support of the crestal cortical bone. Keep the radiograph and the calculation in the patient’s chart as powerful evidence of meticulous patient care. Treatment (Misch & Resnik, 2010). Too much proximity between the implant and a nerveremoval as soon as possible Treatment with corticosteroids and non-steroidal antiinflammatory drugs - to control inflammatory reactions that provoke nervous compression. Topical application of dexamethasone (4 mg/ml) for 1 or 2 minutes enhances recovery, Oral administration (high doses)- within one week of injury- prevention of neuroma formation NEUROPRAXIA Remove offending element Corticosteroids Recovery on 1 to 4 weeks AXONOTMESIS Remove offending element Corticosteroids Recovery on 1 to 3 months NEUROTMESIS Complete anesthesia for more than 3 months May have triggering signs or increase in sensation to sharp stimuli Intraoperative nerve section - microsurgery techniques to reestablish nerve continuity. Neurosensorial loss - checked at different moments to determine with precision the evolution of the lesion Resort to microsurgery if, after four months patient’s situation has not improved, pain persists and there is a remarkable loss of sensitivity. Aspiration and swallowing of instruments Images of a screw driver in the digestive tract. (b) Screw driver into pulmonary tissue. Vital emergency if the instrument has entered the airways. Recommended to tie all tiny and slippery instruments with silk ligatures or else use a rubber dam (Bergermann et al., 1992). Gastroscopy or colonoscopy with a proper medical follow-up required to locate. Flap dehiscence and exposure of graft material or barrier membrane The most common postoperative complication is wound dehiscence, which sometimes occurs during the first 10 days (Greenstein et al., 2008). Wound dehiscence at one week post surgery in a diabetic patient with oral candidiasis Flap tension, Continuous mechanical trauma or irritation associated with the loosening of the cover screw, Incorrect incisions Poor-quality mucosa (thin biotype, traumatized), Heavy smokers, patients treated with corticosteroids, diabetics, or irradiated patients (Lee & Thiele, 2010) Small dehiscence- No surgical correction Large dehiscence Resuturing Free connective tissue grafts - - allows better esthetical results , maintenance of periimplant health (Speroni et al., 2010; Stimmelmayr et al., 2010). 1) Careful preoperative assessment of the soft tissues to measure the amount of keratinized mucosa present and planning of augmentation procedures as appropriate; 2) Minimally invasive flap elevation and reflection with careful removal of any bone débris beneath; 3) Proper suturing; 4) Sensible temporization, rebasing and relining; and 5) Delaying the use of removable dentures until two weeks after surgery. Complications associated with maxillary sinus lift The Schneiderian membrane- characterized by periosteum overlaid with a thin layer of pseudociliated stratified respiratory epithelium, Constitutes an important barrier for the protection and defense of the sinus cavity. Schneiderian membrane perforation occurs in 10% to 60% of all procedures Anatomical variations such as a maxillary sinus septum, spine, or sharp edge are present Very thin or thick maxillary sinus walls Angulation between the medial and lateral walls of the maxillary sinus seemed to exert an especially large influence on the incidence of membrane perforation. Small tears (3mm No loss of bone when compared to baseline, No BOP, no visible plaque OHI and local debridement Surgical resection Plaque+/_ BOP mild OHI and local debridement Surgical resection Topical antiseptic treatment Local antibiotic delivery Systemic antibiotic delivery OHI and local debridement Loss of bone when Topical antiseptic treatment compared to Local/ systemic antibiotic delivery baseline moderate Open debridement OHI and local debridement severe Local/systemic antibiotic delivery Open debridement Explantation Cumulative Interceptive Supportive Therapy (CIST) modalities (Lang et al, 2004). A. using rubber cups and polishing paster, acrylic scalers for chipping off calculus. Effective oral hygiene practices. B. Rinses with 0.1% to 0.2% chlorhexidine digluconate for 3 to 4 weeks, supplemented by irrigating locally with chlorhexidine (preferably 0.2% to 0.5%) : 1. SYSTEMIC ornidazole (2 x 500 mg/day) or metronidazole (3 x 250 mg/day) for 10 days OR combination of metronidazole (500 mg/day) plus amoxicillin (375 mg/day) for 10 days. 2. LOCAL: application of antibiotics using controlled release devices for 10 days (25% Tetracycline fibers). D. Surgical approach: 1. using abundant saline rinses at the defect, barrier membranes, close flap adaptation and careful post-surgical monitoring for several months. Plaque control is to be assured by applying chlorhexidine gels. 2. Apical repositioning of the flap following osteoplasty around the defect. Esthetic complications Depends on patient s esthetic expectations and patient related factors(bone quantity and quality). Depends on individual perceptions and desires : Poor implant placement Deficiencies in the existing anatomy of the edentulous sites Crown form, dimension, shape and gingival harmony is not ideal Esthetic regions: high esthetic demands, thin periodontium, lack of hard and soft tissue support in the anterior esthetic regions Reconstructive procedures to develop a natural emergence profile of the implant crown Appropriate treatment planning and implementation Phonetic complications Implant prosthesis with Unusual palatal contours ( Restricted or narrow palatal space) Spaces under and around the superstructure of implant Mostly observed in severe atrophied maxilla Management: implant assisted maxillary- overdenture Postoperative maxillary sinusitis Maxillary sinusitis can occur qContamination of the maxillary sinus with oral or nasal pathogens or qvia ostial obstruction caused by postoperative swelling of the maxillary mucosa, qNon-vital bony fragments floating freely in the maxillary sinus. qLack of asepsis during sinus augmentation (Timmenga et al., 2001) Preoperative evaluation of sinus clearance-related factors Postsurgery: a nasal decongestant (xylomethazoline 0.05%) and topical corticosteroid (dexamethasone 0.01%) to prevent postsurgery obstruction of the ostium Perioperative antibiotic prophylaxis (cephradine 1 g 3 times daily, starting 1 hour before surgery and continued for 48 hours after surgery) Failed osseointegration Osseointegration was originally defined as a direct structural and functional connection between ordered living bone and the surface of a load-carrying implant (Albrektsson et al. 1994). Osseointegration between an endosseous titanium implant and bone can be expected greater than 85% of the time when an implant is placed. Factors Comments Implant failure Previous failure Surface roughness Surface purity and sterility Fit discrepancies Intra-oral exposure time Mechanical overloading Premature loading Traumatic occlusion due to inadequate restorations Patient(local factors) Oral hygiene Gingivitis Bone quantity/quality Adjacent infection/inflammation Presence of natural teeth Periodontal status of natural teeth Impaction of foreign bodies (including debris from surgical procedure) in the Patient( systemic factors) Vascular integrity Smoking Alcoholism Predisposition to infection, e.g. age, obesity, steroid therapy, malnutrition, metabolic disease (diabetes) Systemic illness Chemotherapy/radiotherapy Hypersensitivity to implant components Surgical technique/environment Surgical trauma Overhea4ng (use of handpiece) Perioperative bacterial contamination, e.g. via saliva, perioral skin, instruments, gloves, operating room air or air expired by patient Conclusion Dental implant placement is not free of complications, as complications may occur at any stage. Careful analysis via imaging, precise surgical techniques and an understanding of the anatomy of the surgical area are essential in preventing complications. Prompt recognition of a developing problem and proper management are needed to minimize postoperative complications. Thank you