Implant Surgery Complications: Etiology and · PDF fileImplant Surgery Complications: Etiology and Treatment Kelly Misch, DDS,* and Hom-Lay Wang, DDS, MSD, PhD† Surgical complications

Implant Surgery Complications:Etiology and Treatment

Kelly Misch, DDS,* and Hom-Lay Wang, DDS, MSD, PhD†

Surgical complications duringimplant placement are not un-common. According to a retro-

spective study by McDermott et al,1

677 patients (2379 implants) were in-vestigated, and an overall frequency ofcomplications was 13.9%. Operativecomplications made up a mere 1% ofthe overall, whereas inflammatory andprosthetic complications were 10.2%and 2.7%, respectively. Complicationsare expected and can lead to a numberof poor treatment outcomes. The aimof this article was to address the etiol-ogy, and emphasize the potential prob-lems as well as, basic treatments thatoccur during the surgical phases ofimplant treatment. Complications canbe outlined in 4 categories (Fig. 1):treatment plan-related, anatomy-related, procedure-related, and other.

TREATMENTPLAN-RELATED COMPLICATIONS

Well organized, thorough treat-ment plans lead to successful implanttreatment and patient satisfaction,which are the ultimate long-termgoals. Patient selection is one of themost important determinants of suc-cess or of failure. Implant treatmentplanning should begin with reviewingpertinent medical history informationand identifying any possible contrain-dications to anticipate problems beforethey occur. Predictability of implantsuccess can be jeopardized by absolute

and relative risk factors. For example,an 11 year retrospective study done byMoy et al,2 showed relative risk ratios(RR): increasing age (60–79 y/o) hada strong association on risk with im-plant failure (RR ! 2.24), as well assmoking (RR ! 1.56), diabetes (RR !2.75), head and neck radiation (RR !2.73), and postmenopausal estrogentherapy (RR ! 2.55).

Wrong Angulation

Implant angulation is yet anotherdeterminant for implant success.Proper angulation should be determinedaccording to the future prosthesis with theconsideration of bucco-lingual, apico-coronal, and mesio-distal positions.To place implants based on availablebone often results in poor esthetic out-comes as well as long-term biome-chanical instability. Although, thereare many “rescue techniques” for re-storing cases placed outside of the oc-clusion (eg, having to be with customand angled abutments), the surgeryshould be planned for suitable angula-tion at the onset. Surgical guides canhelp control the implant placementangle if they are made and used cor-rectly. Choi et al3 investigated theeffects of dimensional factors of thesurgical guides on implant placementand found that the length of the guidechannel was the primary factor in re-ducing angle deviations in the mesio-distal and bucco-lingual direction. It

should be noted that computer-aidedguides,4,5 made with no channel (eg,vacuum-formed matrix) and only a hole,do not merit angulation guidance.

Mandibular teeth in the naturaldentition are lingually inclined in re-lation to both the mandibular base,6specifically as 109 degrees,7 as well asthe maxillary opposing arch dentition(eg, lingual cusp buccal inclinatio-n)and therefore implants should beplaced at a similar inclination. Failureto do so may result in perforation ofthe lingual concavity, constriction ofthe lingual space or damage of thelingual artery. Restorations may bedifficult to restore due to tongueimpingement or incorrect opposingpositions. In the posterior mandible,limited mouth opening prevents thedrill and implant carrier from fittingcorrectly in the vertical direction.Teeth adjacent to implant sites andsurgical guides with long drill chan-nels, often require the use of drill ex-tensions and maximum opening by thepatient which may be strenuous. Shortbreaks to relieve muscle tension, usinga bite block and having the patientshift their jaw to the opposite side canhelp ensure the correct angulation ofthe drill.

Yet another type of problem lead-ing to incorrect implant angulation isthe use of a finger rest while drilling(Fig. 2). Dentists have traditionallybeen taught to stabilize their hands by

*Periodontics Resident, Department of Periodontics and OralMedicine, School of Dentistry, University of Michigan, AnnArbor, MI.†Professor and Director of Graduate Periodontics, Departmentof Periodontics and Oral Medicine, School of Dentistry,University of Michigan, Ann Arbor, MI.

ISSN 1056-6163/08/01702-159Implant DentistryVolume 17 • Number 2Copyright © 2008 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3181752f61

Implant surgery complications arefrequent occurrences in dental practiceand knowledge in the management ofthese cases is essential. The aim of thisreview was to highlight the challenges oftreatment plan-related, anatomy-related, and procedure-related surgical

complications as well as to discuss theetiology, management and treatment op-tions to achieve a satisfactory treatmentoutcome. (Implant Dent 2008;17:159–168)Key Words: dental implants, implantcomplications, implant failures

IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 159

placing a finger on adjacent teeth orthe chin while using instruments/handpieces during periodontal and op-erative work to stabilize the hand aswell as to reduce the muscle fatigue,but implant dentistry is different. Dueto the length of implant drills("10#20 mm), using a finger restwhile drilling, results in an inclinationof the drill towards the hand that issteadied. Hence, using finger rests isan ergonomic principle that should notbe used for implant placement.

Surgical guides and proper treat-ment planning can alleviate angulationproblems, but even so, angled abut-ments are hot selling items becauseclinicians are failing to abide by thisimportant principle. The development ofangled abutments has been a rescuetechnique for these wrongly placed im-plants and allows for a more successfulesthetic outcome. In summary, use asurgical guide with a long channel thatdoes not give leeway to veer and com-municate with the restorative doctor.

Improper Implant Location

Adjacent teeth should be at least1.5 mm from the implant body8 andmore than 3 to 4 mm between adjacent

implants to prevent horizontal boneloss as well as to preserve esthetics.9Preoperative measurements and plan-ning are essential to achieve an idealimplant placement that facilitatesfuture implant prosthesis. Placing animplant in the wrong location is a frus-trating, embarrassing and avoidablecomplication (Fig. 3). Measurements(eg, interocclusal, interdental, ridgeheight, and ridge width) confirmwhether implants are indicated in thefirst place. The spatial orientationshould be in line with the occlusalplane and centered according to theopposing occlusion to prevent cross-bites or additional stresses on the pros-thesis. Many times fixtures are ideallyintended for one specific position to bein the proper occlusion (Fig. 4). Ifmore than one implant is to be placed,a diagnostic wax-up should be used todetermine the correct implant loca-tions. At the very least, drawing andmeasuring on the stone casts will al-low for calculations and treatmentplanning.

Hypothetically, a surgical compli-cation could also occur, but not berealized by the surgeon at the actualtime of surgery, especially when plac-

ing multiple implants. For example,Tarnow et al9 demonstrated in a retro-spective study assessing 36 patients,that an implant placed $3 mm awayfrom an adjacent implant can have ad-equate stability and function but maylater result in lateral bone loss. Yetanother issue to keep in mind whenplacing the implant is to measure thevertical distance between the base ofthe prosthetic contact point and thecrestal bone. Tarnow et al10 found thatif the distance was 5 mm or less, 98%of the time the embrasure space filledin, but as the distance increases to 6and 7 mm, the presence of a papillareduces to 56% and 27%, respectively.de Oliveira et al11 found that as long as5 mm distance is maintained betweencontact point and alveolar bone crest,it does not make a difference in papillaformation or bone loss, whether theadjacent implants are 1, 2, or 3 mmapart from each other.12

Lack of Communication

An informed consent form is anexcellent way of communicating po-tential surgical risks and complica-tions to a patient. Common problemsto address include but are not limitedto postoperative infection, bleeding,swelling, facial discoloration, tran-sient pain, paresthesia, neuralgia, frac-ture, joint pain, muscle spasm, toothlooseness and sensitivity, recession,speech change, trismus, and swallowing

Treatment Plan Related

Wrong angulation Improper implant

location Too close

Too far apart Lack of communication

Anatomy Related

Nerve injury Bleeding

Cortical plate perforation

Sinus perforation Devitalization of adjacent teeth

Other Iatrogenic

Human error

Procedure

Related Lack of primary

stability Mechanical

complications Mandibular fracture Ingestion/aspiration

Implant

Complications

Fig. 1. Outline of common complications during implant surgery.

Fig. 2. Example of using a finger rest.Fig. 3. Implant positioned too buccally.

160 IMPLANT SURGERY COMPLICATIONS

of foreign objects. Should a complica-tion occur during the post operativehealing time, it is recommended togive emergency contact informationas well.

In the United States, 12.1% ofmedical malpractice payment reportswere against dentists in 2002.13 In den-tistry, the main causes for lawsuits areactual body injury (eg, loss of sensa-tion, oroantral fistula, life-threateningbleeding) and major disappointment.14

This could be avoided if a patientunderstands the fundamentals of thesurgical procedure and what is to beanticipated. A valuable tool used tocommunicate between surgeons’ andrestorative doctors is a surgical guide.The sole purpose of fabricating theguide is to identify the correct locationand angulation for implant placementwhich will undoubtedly reduce/elimi-nate unnecessary surgery/prostheticcomplications. Surgical guide designsinclude the labial outline surgicalguide fabricated from a wax arrange-ment of the intended definitive restora-tion,15 a clear vacuum-formed matrix,16 aduplicate of the existing restoration,17

a light-polymerized composite mate-rial and drill blanks with a diagnosticcast,18 as well as many other methods.

ANATOMY-RELATEDCOMPLICATIONSNerve Injury

When placing implants in themandible, proper radiographs and pre-

treatment planning must be done toensure complete aversion of the infe-rior alveolar, mental, incisive or lin-gual nerves. If the mandibular canalcannot be seen on a panoramic radio-graph, a computer tomography (CT)scan should be taken to verify the lo-cation. The potential risks and compli-cations of injury or damage to thesevital structures should be included onthe informed consent to avoid liabilityin cases of lawsuits.

Possible causes of nerve injury in-clude poor flap design, traumatic flapreflection, accidental intraneural injec-tion, traction on the mental nerve in anelevated flap, penetration of the os-teotomy preparation and compressionof the implant body into the canal.

To circumvent trauma to the infe-rior alveolar nerve (IAN), some clini-cians suggest local infiltrating insteadof a mandibular nerve block. This ideais a safety precaution to avoid havingthe drill approach too close to the ca-nal.19 Overpenetration occurs whenthe cortical portion of the alveolarcrest puts resistance on the drill, but asit enters the marrow spaces, it dropsinto the neurovascular bundle. Worth-ington20 investigated penetration intothe IAN canal in human cadavers andrecommended reviewing radiographsbefore surgery using the correct mag-nification as well as, allowing a 1 to 2mm safety zone. This distance is toaccommodate the Y dimension of thedrill (apical extent of the tip which

gets longer as the implant diametergets wider), where it ranges from 1mm (3.4 mm drill) to 1.45 mm (4.85mm drill) as well as 1 mm thickness ofcortical plate above the mandibular ca-nal (unpublished data).

Bartling et al21 observed 405 man-dibular endosseous implants placed in94 patients to determine the incidenceof altered sensation using standardneurologic tests over a 6-month pe-riod. An incidence of 8.5% was foundat the first postoperative appointment.Only 1 patient experienced completeanesthesia for 2 months. This was laterresolved by 4 months. Unique to thisstudy was that no permanent altered sen-sation was found for any of the subjectsover the 6 months. Van Steenbergheet al,22 also reported a similar incidencerate of 6.5% for altered sensation at 1year after mandibular implant place-ment. In contrast, other studies havereported higher rates. Ellies andHawker23 found an altered sensationincidence of 36%, of which 10% to15% of those patients never regainedsensation.

Radiographs should be taken ifthe surgeon has any doubt about wherethe drill is or if the drill or implant isin close proximity to or invading, neu-ral anatomical structures. If the situa-tion is the latter, the implant needs tobe removed, or a shorter body implantshould be placed instead. Within daysor months, minor trauma injuries usu-ally heal but permanent damage fromneuritis can occur. Treatment optionsinclude neuronal anti-inflammatorydrugs such as clonazepam, carbamaz-epine or vitamin B-complex,24 al-though marginal effects have beenshown. Referral and treatment for IANinjuries should be done immediatelybefore distal nerve degeneration de-velops.25 According to Hegedus andDiecidue,26 follow-up appointmentsshould take place at 4, 8, and 12 weeksafter placement and each visit shouldinclude documentation of subjectivesymptoms, oral/facial function andatrophic/cutaneous changes. The pa-tient should then be referred for mi-crosurgery if total anesthesia persists,or if after 16 weeks, if dysesthesia ison-going.24,27 Timely referral for mi-croneurosurgery is necessary to re-establish nerve continuity, improve

Fig. 4. Example of a poor initial treatment plan. No. 19 implant (a) was placed too far from thesecond premolar causing the fixed crown to be cantilevered mesially to obtain contact with theadjacent tooth but (b) too much stress may have caused the alveolar bone loss evident at the crestand surrounding the implant body. The mesial implant (c) was removed and replaced (d) with 2additional implants to alleviate complications.


sensation and motor skills and to pos-sibly relieve pain.26

Bleeding

Life-threatening events associatedwith dental implants are rare but majorcomplications such as severe hemor-rhage are more common and Goodacreet al,28 found hemorrhage-related im-plant complications had an incidenceof 24%. Potential causes include inci-sion of arteries in soft tissue, osteot-omy preparation, and lateral wall sinuslift procedures.

Kalpidis and Konstantinidis29 re-ported a case involving a perforationof the lingual cortical plate during animplant osteotomy preparation of thefirst mandibular premolar position. Acritical hemorrhage and multiple he-matomas immediately occurred afterperforation which was verified by aCT scan.

Risk sites30 as described above inthe posterior mandible include thesublingual fossa and lingual cortex. Aruptured artery in the area within 30minutes, can cause a blood loss rate of14 mL/min31 and if %500 mL of bloodloss occurs, hypotension can result.32

Life-threatening airway obstruction isa serious threat and early treatment isessential. Treatment involves havingthe patient stick out their tongue tocompress the blood vessels against thebody of the mandible. Placing pres-sure with gauze in the sublingual areadoes not work as one would intuitivelythink. Extraoral pressure to the sub-mental or submandibular arteries for20 minutes against the body of themandible helps.33

The posterior superior alveolarand infraorbital arteries are locatedapproximately 19 mm above the max-illary alveolar ridge,34 and the anasto-moses of these arteries can pose a riskduring sinus lift procedures by lateralwindow preparation. Bone wax, pres-sure, crushing, and electrocautery canalleviate hemorrhage. In summary,hemorrhage treatments at implant os-teotomy sites include compression,finger pressure, vasoconstriction, cau-tery, bone graft, bone cement, and li-gation of arteries.33

Cortical Plate Perforation

The buccal cortical plate varies inthickness throughout the mouth and

traumatic dental extractions can causemarkedly thin plates or concavities, aswell as overall ridge width deficiency.35

When preparing osteotomy sites orplacing implant fixtures in areas withminimal labial plate thickness, or ifthe implant is placed too buccally, afenestration or dehiscence implant de-fect is a common finding. A fenestra-tion leaves intact bone coronally withthe exposed threads at the apical por-tion of the crest, whereas a dehiscencedefect has the coronal portion of theimplant exposed. Tinti et al,36 furtherclassified these defects as Class I if theimplant was within the envelope ofbone and Class II if it was left stayingoutside the envelope. Immediate cor-rection with particulate bone graftingwith or without a membrane duringthe time of implant placement, can bedone as long as primary stability hasbeen achieved. “Flapless” implant sur-geries should be avoided in areas ofpotential perforation of the buccal orlingual bone.

Sinus Membrane Complications

In the maxillary posterior, theproximity of the sinuses37,38 can createa problem for dental implants if thereis minimal residual crestal bone ($5mm) for stability. The maxillary sinuslift technique is an accepted proce-dure, demonstrated by Tatum,39 toaugment vertical height in the severelyresorbed posterior maxilla area to fa-cilitate proper implant placement. Si-nus complications often occurredwhen the membrane is perforated attime of surgery. Ardekian et al40 foundmaxillary sinus membrane perfora-tions were more common in areas withminimal amount ($5 mm) of residualalveolar bone but this did not affectthe overall implant success rate. Nostatistical differences were found be-tween the perforation group comparedwith the intact membrane group. Incontrast, Proussaefs et al41 found im-plant survival at second-stage surgerywas superior for the nonperforatedsites (100%) compared with perfo-rated sites (69.6%). Bone density aftergrafting should be assessed, regardlesswhether or not a perforation occurs,because poor bone quality often leadto a higher implant failure rate.34

What happens if an implant pro-trudes into the maxillary sinus cavity

(Fig. 5)? Jung et al42 reported the riskof maxillary sinus complications inimplants which penetrated the boneand mucous membrane of the sinusfloor at 2, 4, and 8 mm extensions.After 6 months, radiographic and his-tologic examinations did not show anysigns of pathologic findings in themaxillary sinus of the 8 dogs. Despitethe convincing results, the question re-mains whether 6 months is a longenough follow-up period. Hence, ithas been suggested that simultaneousimplant placement during sinus liftprocedures is not considered a contra-indication or less predictable proce-dure. Nonetheless, careful planningand precise surgery execution are es-sential to avoid any potential sinuscomplications.

Lastly, losing an implant into themaxillary sinus is a relatively uncom-mon surgical complication. However,in cases with less than 5 mm of bone,mastication can cause the implants tomove during the graft maturationtimeframe.43 Transantral endoscopicsurgery is a reliable, minimally inva-sive method for retrieving displacedobjects from the maxillary antrumwith minimal complications,44,45 but itdoes require having an endoscope or areferral to an ENT or oral surgeon.

Devitalization of Adjacent Teeth

Adjacent teeth at implant recipientsites should be evaluated before implantplacement. Pulpal and periradicularconditions such as small periapical ra-diolucencies, root resorption and largerestorations in/near the vital pulp areoften misdiagnosed. Numerous casereports33,46,47 describe implant pathosiscaused by dormant endodontic prob-lems of adjacent teeth that flare upafter implant surgery.48 Therefore, it is

Fig. 5. Implant placed into the maxillary sinus.


worth the time of pulp testing suspi-cious teeth and completing a thoroughradiographic examination. If endodon-tic pathosis is identified, root canaltreatment or extraction should be ini-tiated before implant placement to pre-vent microbial contamination of theimplant49 during healing and possiblefailure.

Dilacerated roots and excessivetilting in the mesiodistal direction thatinvade the implant space often preventideal placement. If a drill and/or im-plant fixture invades the PDL, hardtooth structure and/or vital pulp, thiswill lead to endodontic lesions.50 De-vitalization of an adjacent tooth nextto an implant delays treatment andadds additional financial burden forboth the patient and surgeon. A propersurgical guide and a careful radio-graph analysis are necessary to avoidimproper angulation and hidden dilac-erated roots.

PROCEDURE RELATEDMechanical Complications

Situations deeming an implant as“hopeless” are usually associated withsurgical trauma during osteotomypreparation with the drill. Ericssonand Albrektsson51 showed bone re-sorption occurred at 47°C when dril-ling was applied for more than 1minute in rabbits. The result obtainedfrom this study leads to the conclusionthat if temperature or duration in-creases while drilling in bone, necrosiscan occur causing detrimental effectsfor osseointegration. Nonetheless,Ercoli et al52 later reported that theharmful temperature only occurredwhen drilling was continuous or whenthe drill reached beyond 15 mm during5 osteotomies.

Dense cortical bone (eg, type Ibone quality), when compared withtype III or IV soft cancellous bone,can be overheated when preparing os-teotomies because more pressure isneeded to advance the drill apically incomparison to soft bone. To reducefrictional heat, high speed handpieces,an up-down motion technique of thebone preparation, and copious irriga-tion can be used. Misch53 recommendsusing external and/or internal irriga-tion, as well as cool saline irrigation,intermittent pressure on the drills,

pausing every 3 to 5 seconds, usingnew drills, and an incremental drillsequence. Generating less heat by pre-paring implant sites at 2500 rpm maydecrease osseous damage.54

Tapping dense cortical bone issuggested. The benefits of tapping in-clude limiting full osteotomy depth,allowing passive implant fit, prevent-ing internal implant-body/implant-bone interface microfracture, andcompression necrosis, and removingdrill remnants.53

According to Quirynen et al,55

overpreparation or overheating osteot-omies can result in inactive and activeretrograde peri-implantitis lesions thatcan be detected on radiographs as peri-apical radiolucencies up to a monthafter insertion.47 A good example of aninactive lesion is placing a shorter im-plant into a larger prepared osteotomysite. Clinically, these lesions areasymptomatic and radiographically,they present as periapical radiolucen-cies. As long as the radiolucency staysstable in size and the implant is inte-grated, no treatment is necessary. Incontrast, problems with microbial in-vasion during surgery, such as implantcontamination during insertion orplacing the implant into an area withprevious inflammation (eg, endodon-tic lesion) can lead to active lesions. Arisk of successful treatment can beconsidered in extraction sites with ahistory of failed endodontic treatmentor adjacent teeth with endodonticpathology.55

Esposito et al,56 during a reviewof literature to find diagnostic criteriafor monitoring implant conditions,found that surgical trauma and ana-tomical conditions both were the mostsignificant etiologic factors for earlyimplant failures in Branemark im-plants (3.63%). Interestingly, the ITIimplants had higher losses due to peri-implantitis and the authors attributeddesign and surface type as the prob-lem. Early implant failures are due toexcessive surgical trauma along withimpaired wound healing, prematureloading and infection.56

Lack of Primary Stability

Lack of primary stability is a sur-gical complication that should be dealtwith at the time of implant surgery. Anunstable implant (eg, a “spinner”)

should be removed or an attempt toplace a larger diameter should be com-pleted. To leave an unstable implantwithout action can often lead to fi-brous encapsulation that causes im-plant failure.57 Nonetheless, bone fillwill occur in immediate implantsplaced into extraction sockets with amarginal defect lateral to the implantwider than 1 mm58 but primary stabil-ity is still a requirement.

Mandibular Fracture

The mandible is the most fre-quently fractured facial bone,59 manyfactors have been proposed to contrib-ute to the fractures. These include butare not limited to site, direction andseverity of the force as well as im-pact.60 Attempts to place implants inpatients with severely atrophic mandi-bles increases the risk of fracture, es-pecially when monocortical grafts andridge-splitting surgeries are com-pleted. In patients who present withosteomalacia or osteoporosis, implantplacement may subject the brittle boneto splintering because of the loading orfrictional forces.61 Other reasons formandibular fracture may include usingthe wrong implant (eg, 10 mm sitepreparation with intent of placing a 12or 14 mm implant). Checking the im-plant size/diameter before opening thepackage is important.

A fracture of the mandible shouldbe restored to maintain form and func-tion. Management should includestabilization with an attempt to alsosimultaneously eliminate atrophy ifindicated. A retrospective study byEyrich et al62 found that treatment formandibular fractures should be basedon the type and location of the frac-ture, as well as the severity of theatrophy. Treatment options includedusing the wiring of a modified pros-thesis, lag screws, wires and plates.The most relevant option of our fieldincludes combined bone augmentation,fixation and simultaneous implantplacement. Increasing mandibularheight after augmentation may be un-predictable but using implants concur-rently may reduce bone resorption. Ifan implant lies in the line of fracture,osseointegration will still occur as longas there is no mobility or infection.63

Another recommended approach formandibular fracture is using reduction and


immobilization with monocorticalminiplates to avoid any nonunion andmalunion healing.33 Two miniplates ora combination with microplates canobtain stable fixation in severely atro-phic fractured mandibles and is a lessinvasive treatment option.64

Ingestion and Aspiration

For the sake of completeness, itshould be mentioned that extreme cau-tion should be emphasized when han-dling small implant components in theoral cavity. Most instruments have aspecial tip to help ensure screws andabutments transfer directly from thesurgical tray into the patient’s mouth,but nevertheless, accidents happen.Unfortunately, components windingup on the floor or down a patient’sthroat can be embarrassing and expen-sive mishaps, not to mention seriousimplications could occur if aspirationtakes place. For these reasons, preven-tative measures such as gauze throatscreens and floss ligatures on implantpieces are encouraged.

Tiwana et al,65 found over a 10 yearretrospective institutional study, only 36cases of ingestion were reported andamazingly only one case of aspiration.Fixed prosthodontic therapy reportedhaving the most incidences of ingestion.In particular, cemented single-tooth castor prefabricated restorations had ahigher likelihood of aspiration.

If a patient swallows or aspiratesan implant component, they should bereferred to the hospital because acuteobstruction can be life threateningand prolonging the removal of for-eign objects may make a bronchos-copy technically more difficult.66 Ifthe foreign object is aspirated itshould be removed within 24 hours.Chest radiographs are a diagnostictool available to rule out ingestion oraspiration.

Other

A study done by the Dental Im-plant Clinical Research Group67 foundthat inexperienced surgeons ($50 im-plants) were twice as likely to haveimplant failures compared with moreexperienced surgeons. Such a statistic isa good reminder in realizing that someof our literature is based on the work ofgraduate students who start out as ama-

teur implant surgeons hence the datacannot be generalized. The realizationalso exists that many general dentistsstarting to place implants may havemore failures and complications com-pared with experienced specialists.

CONCLUSION

Surgical implant complicationsare not uncommon and should be ad-dressed immediately. Causality maybe iatrogenic, due to poor treatment

techniques, or lack of communicationbetween dental disciplines. Timeshould be spent in the implant “plan-ning” stages, such as tracing preoper-ative radiographs, measuring models,taking CT scans and making propersurgical guides. Basic anatomy mustnot be forgotten and should be reviewedby the surgeon in every case. As moresurgically inexperienced dental profes-sionals start placing implants an in-crease in surgical complications will

Accumulate data Medical history, dental history, radiographs, CT, models Assemble treatment plan

Exam, discuss all options, review plan with all disciplines (surgical, restorative, patient and lab)

Approve treatment plan Signed consent. Patient should understand all risks, benefits, complications and fees

Anticipate problems Anatomical

Nerves (<1mm from implant), vessels, adjacent teeth (<.5 mm from implant), type IV bone & sinus/nasal floor

Mechanical Drilling torque, lack of irrigation, incorrect armamentarium, no surgical guide, implant contamination, time constraints

Systemic Medications, smoking, DM, head & neck radiation, estrogen therapy, osteoporosis

Activate treatment Achieve anchorage

No complications, ideal treatment case, primary stability

Analyze compromised situation Dehiscence, fenestration, improper positioning/angulation,

Accommodate problem Bone grafting, membranes, sutures, back-up implant, shorter implants, root canal therapy

Abort treatment Lack of primary stability Over-prepped osteotomy Large dehiscence or fenestration

Nerve trauma Fracture of the mandible Short distance (<1.5 mm from adjacent tooth)

Auxillary Refer when indicated Accomplish treatment Post operative instructions Post operative medications Narcotic, antibiotic, sedative, anti-inflammatory

Fig. 6. A& guidelines for preventing and managing implant complications.


likely occur. In summary, a competentsurgeon should be able to treatmentplan a predictable surgery, (Fig. 6) andrecognize how to remedy a problem-atic dental-implant situation.

Disclosure

The authors do not have any fi-nancial interests, either directly or in-directly, in the products listed in thestudy.

ACKNOWLEDGMENTS

This article was partially supported bythe University of Michigan Periodon-tal Graduate Student Research Fund.

REFERENCES

1. McDermott N, Chuang S, Dodson T,et al. Complications of dental implants:Identification, frequency, and associatedrisk factors. Int J Oral Maxillofac Implants.2003;18:848-855.

2. Moy PK, Medina D, Aghaloo TL, etal. Dental implant failure rates and associ-ated risk factors. Int J Oral Maxillofac Im-plants. 2005;20:569-577.

3. Choi M, Romberg E, Driscoll CF. Ef-fects of varied dimensions of surgicalguides on implant angulations. J ProsthetDent. 2004;92:463-469.

4. Wong N, Huffer-Charchut H, SarmentD. Computer-aided design/computer-aidedmanufacturing surgical guidance for place-ment of dental implants: Case report. ImplantDent. 2007;16:123-130.

5. Jabero M, Sarment DP. Advancedsurgical guidance technology: A review.Implant Dent. 2006:15;135-142.

6. Williams PL, Warwick R. Gray’sAnatomy. 36th ed. Edinburgh: ChurchillLivingstone; 1980:1281-1287.

7. Tanaka T, Shaw P. Anatomy for im-plant dentistry: Mandible. QuintessenceDent Implantol. 1995;2:10-20.

8. Choquet V, Hermans M, Malevez C,et al. Clinical and radiographic evaluationof the papilla level adjacent to single-toothdental implants. A retrospective study inthe maxillary anterior region. J Periodontol.2001;72:1364-1371.

9. Tarnow DP, Cho SC, Wallace SS.The effect of inter-implant distance on theheight of inter-implant bone. J Periodontol.2000;71:546-549.

10. Tarnow DP, Magner AW, Fletcher P.The effect of the distance from the contactpoint to the crest of bone on the presence orabsence of the interproximal dental papilla. JPeriodontol. 1992;63:995-996.

11. de Oliveira RR, Novaes A Jr, TabaM Jr, et al. Influence of interimplant dis-tance on papilla formation and boneresorption: A clinical-radiographic study indogs. J Oral Implantol. 2006;32:218-227.

12. Novaes AB, de Oliveira RR, Taba MJr, et al. The effects of interimplant dis-tances on papilla formation and crestal re-sorption in implants with a morse coneconnection and a platform switch: A histo-morphometric study in dogs. J Periodon-tol. 2006;77:1839-1849.

13. 2002 Annual Report, NationalPractitioner Data Bank, US DHHS.

14. Givol N, Taicher S, Chaushu G, etal. Risk management aspects of implantdentistry. Int J Oral Maxillofac Implants.2002;17:258-262.

15. Parel SM, Funk JJ. The use andfabrication of a self-retaining surgical guidefor controlled implant placement; a techni-cal note. Int J Oral Maxillofac Implants.1991;6:207-210.

16. Blustein R, Jackson R, Godar D, etal. Use of splint material in the placement ofimplants. Int J Oral Maxillofac Implants.1986;1:47-49.

17. Neidlinger J, Lilien BA, Kalant DCSr. Surgical implant stent: A design modi-fication and simplified fabrication tech-nique. J Prosthet Dent. 1993;69:70-72.

18. Shotwell JL, Billy EJ, Oh TJ, et al.Implant surgical guide fabrication for par-tially edentulous patients. J Prosthet Dent.2005;93:294-297.

19. Heller AA, Shankland WE II. Alter-native to the inferior alveolar nerve blockanesthesia when placing mandibular den-tal implants posterior to the mental fora-men J Oral Implantol. 2001;27:127-133.

20. Worthington P. Injury to the inferioralveolar nerve during implant placement: Aformula for protection of the patient andclinician. Int J Oral Maxillofac Implants.2004;19:731-734.

21. Bartling R, Freeman K, Kraut RA.The incidence of altered sensation of themental nerve after mandibular implantplacement. J Oral Maxillofac Surg. 1999;57:1408-1410.

22. Van Steenberghe D, Lekholm U,Bolender C, et al. Applicability of os-seointegrated oral implants in the rehabili-tation of partial edentulism: A prospectivemulticenter study on 558 fixtures. Int J OralMaxillofac Implants. 1990;5:272-281.

23. Ellies L, Hawker P. The prevalenceof altered sensation associated with im-plant surgery. Int J Oral Maxillofac Im-plants. 1993;8:674-679.

24. Nazarian Y, Eliav E, Nahlieli O. [He-brew] Nerve injury following implantplacement: Prevention, diagnosis andtreatment modalities. Refuat Hapeh Ve-hashinayim. 2003;20:44-50.

25. Kraut RA, Chahal O. Managementof patients with trigeminal nerve injuries af-ter mandibular implant placement. JADA.2002;133:1351-1354.

26. Hegedus F, Diecidue RJ. Trigemi-nal nerve injuries after mandibular implantplacement-Practical knowledge for clini-cians. Int J Oral Maxillofac Implants. 2006;21:111-116.

27. Day RH. Microneurosurgery of theinjured trigeminal nerve. Oral MaxillofacSurg Knowledge Update. 1994;1:91-116.

28. Goodacre DJ, RungcharassaengK, Kan JY, et al. Clinical complications withimplants and implant prostheses. J Pros-thet Dent. 2003;90:121-132.

29. Kalpidis CD, Konstantinidis AB.Critical hemorrhage in the floor of themouth during implant placement in the firstmandibular premolar position: A case re-port. Implant Dent. 2005;14:117-124.

30. Longoni. Longoni S, Sartori M, etal. Lingual vascular canals of the mandible:The risk of bleeding complications duringimplant procedures. Implant Dent. 2007;16:131-138.

31. Flanagan D. Important arterial supplyof the mandible, control of an arterial hemor-rhage, and report of a hemorrhagic incident.J Oral Implantol. 2003;29:165-179.

32. Baab DA, Ammons WF Jr, SelipskyH. Blood loss during periodontal flap sur-gery. J Periodontol. 1977;48:693-698.

33. Park S-H, Wang H-L. Implant re-versible complications: Classification andtreatments. Implant Dent. 2005;14:211-220.

34. Fugazzotto PA, Wheeler SL, Lind-say JA. Success and failure rates of cylin-der implants in type IV bone. J Periodontol.1993;64:1085-1087.

35. Katranji A, Misch K, Wang H-L.Cortical bone thickness in dentate andedentulous human cadavers. J Periodon-tol. 2007;78:874-878.

36. Tinti C, Parma-Benfenati SP. Clini-cal classification of bone defects concern-ing the placement of dental implants. Int JPeriodontics Restorative Dent. 2003;23:147-155.

37. Shin HI, Sohn DS. A method ofsealing perforated sinus membrane andhistologic finding of bone substitutes: Acase report. Implant Dent. 2005;14:328-335.

38. Kim S-G, Mitsugi M, Kim B-O. Si-multaneous sinus lifting and alveolar dis-traction of the atrophic maxillary alveolusfor implant placement: A preliminary re-port. Implant Dent. 2005;14:344-348.

39. Tatum H. Maxillary and sinus im-plant reconstructions. Dent Clin North Am.1986;30:207-229.

40. Ardekian L, Oved-Peleg E, PeledM, et al. The clinical significance of sinusmembrane perforation during augmenta-tion of the maxillary sinus. J Oral MaxillofacSurg. 2006;64:277-282.

41. Proussaefs P, Lozada J, RohrerMD, et al. Repair of the perforated sinusmembrane with a resorbable collagenmembrane: A human study. Int J Oral Max-illofac Impl. 2004;19:413-420.

42. Jung JH, Choi BH, Li J, et al. Theeffects of exposing dental implants to themaxillary sinus cavity on sinus complica-tions. Oral Surg Oral Med Oral Pathol OralRadiol Endod. 2006;102:602-605.


43. Peleg M, Garg AK, Mazor Z. Pre-dictability of simultaneous implant place-ment in the severely atrophic posteriormaxilla: A 9-year longitudinal experiencestudy of 2,132 implants placed into 731human sinus grafts. Int J Oral MaxillofacImplants. 2006;21:94-102.

44. Nakamura N, Mitsuyasu T, OhishiM. Endoscopic removal of a implant dis-placed in the maxillary sinus; a technicalnote. Int J Oral Maxillofac Surg. 2004;33:195-197.

45. Varol A, Turker N, Basa S, et al.Endoscopic retrieval of dental implantsfrom the maxillary sinus. Int J Oral Maxillo-fac Implants. 2006;21:801-804.

46. Oh T-J, Joongkyo Y, Wang H-L.Management of the implant periapicallesions: A case report. Implant Dent. 2003;12:41-46.

47. Ayangco L, Sheridan PJ. Develop-ment and treatment of retrograde peri-implantitis involving a site with a history offailed endodontic and apicoectomyprocedures: A series of reports. Int J OralMaxillofac Implants. 2001;16:412-417.

48. Shaffer MD, Juruaz DA, HaggertyPC. The effect of periradicular endodonticpathosis on the apical region of adjacentimplants. Oral Surg Oral Med Oral PatholOral Radiol Endod. 1998;86:578-581.

49. el Askary AS, Meffert RM, Griffin T.Why do dental implants fail? Part I. ImplantDent. 1999;8:173-185.

50. Sussman HI. Tooth devitalizationvia implant placement: A case report. Peri-odontal Clin Investig. 1998;20:22-24.

51. Ericksson RA, Albrektsson T. Tem-perature threshold levels for heat-inducedbone tissue injury: A vital-microscopic

study in the rabbit. J Prosthet Dent. 1983;50:101-107.

52. Ercoli C, Funkenbusch PD, Lee HJ,et al. The influence of drill wear on cuttingefficiency and heat production during os-teotomy preparation for dental implants: Astudy of drill durability. Int J Oral MaxillofacImplants. 2004;19:335-349.

53. Misch CE. Contemporary ImplantDentistry. 2nd ed. St. Louis, MO: Mosby;1999:373.

54. Sharawy M, Misch CE, Tehemar S,et al. Heat generation during implantdrilling: The significance of motor speed.J Oral Maxillofac Surg. 2002;60:1160-1169.

55. Quirynen M, Gijbels F, Jacobs R.An infected jawbone site compromisingsuccessful osseointegration. Periodontol2000. 2003;33:129-144.

56. Esposito M, Hirsch JM, ThomsenP, et al. Biological factors contributing tofailures of osseointegrated oral implants.(I). Success criteria and epidemiology. EurJ Oral Sci. 1998;106:527-551.

57. Lioubavina-Hack N, Lang NP,Karring T. Significance of primary stabilityfor osseointegration of dental implants.Clin Oral Impl Res. 2006;17:244-250.

58. Botticelli D, Berglundh T, Lindhe J,et al. The jumping distance revisited: Anexperimental study in the dog. Clin OralImplants Res. 2003;14:35-42.

59. Olson RA, Fonseca RJ, Osbon DB,et al. Fractures of the mandible: A review of580 cases. J Oral Maxillofac Surg. 1982;40:23-28.

60. Reitzik M, Lownie JF, Austin J, etal. Experimental fractures of monkey man-dibles. Int J Oral Surg. 1978;7:100-103.

61. Hohlweg-Majert B, Schmelzeisen

R, Schneider E, et al. Significance of osteo-porosis in craniomaxillofacial surgery: A re-view of the literature. Osteoporos Int.2006;17:167-179.

62. Eyrich GKH, Gratz KW, Sailer HF.Surgical treatment of fractures of the eden-tulous mandible. J Oral Maxillofac Surg.1997;55:1081-1087.

63. Tolman DE, Keller EE. Manage-ment of mandibular fractures in patientswith endosseous implants. Int J Oral Max-illofac Implants. 1991;6:427-436.

64. Mugino H, Takagi S, Ikemura K, etal. Miniplate osteosynthesis of fractures ofthe edentulous mandible. Clin Oral Inves-tig. 2005;9:266-270.

65. Tiwana K, Morton, Tiwana PS. As-piration and ingestion in dental practice: A10-year institutional review. JADA. 2004;135:1287-1291.

66. Zitman NU, Marinello CP. The as-piration and swallowing of foreign bodies.The management of the aspiration or swal-lowing of foreign bodies during dentaltreatment. Schweiz Mon atsschr Zah-nmed. 2000;110:619-632.

67. Truhlar RS, Morris HF, Ochi S, et al.Second stage failures related to bone qual-ity in patients receiving endosseous dentalimplants DICRG, Interim report #7. ImplantDent. 1994;3:252-255.

Reprint requests and correspondence to:Hom-Lay Wang, DDS, MSD, PhDDepartment of Periodontics and Oral MedicineUniversity of Michigan, School of Dentistry1101 N. UniversityAnn Arbor, MI 48109-1078Phone: 734-763-3383Fax: 734-936-0374E-mail: [email protected]

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Kelly Misch, DDS, Hom-Lay Wang, DDS,MSD, PhD. Korrespondenz an: Hom-Lay Wang., DDS., MSD,PhD, Abteilung fur Parodontie und Oralmedizin (Dept. of Pe-riodontics and Oral Medicine), Universitat von Michigan (Uni-versity of Michigan), zahnmedizinische Fakultat (School ofDentistry), 1101 N. University, Ann Arbor, MI 48109-1078.Telefon: 734-763-3383, Fax: 734-936-0374, eMail: [email protected] bei Implantationsoperationen: Atiologie &Behandlung

ZUSAMMENFASSUNG: In der Zahnheilkundlichen Praxistreten haufig Komplikationen bei Implantierungsoperationenauf. Es ist von maßgeblicher Bedeutung, hier uber eine mo-

glichst erfolgreiche Problembewaltigung Bescheid zu wissen.Die vorliegende Studie zielt darauf ab, die Herausforderun-gen hinsichtlich der Behandlung von Komplikationen inVerbindung mit dem Behandlungsplan, der spezifischenPatientenanatomie und dem Behandlungsvorgehen heraus-zustellen sowie die Atiologie und die Optionen fur Problem-bewaltigung und Behandlung mit dem Ziel eines zufriedenstellenden Behandlungsergebnisses zu diskutieren.

SCHLUSSELWORTER: Zahnimplantate; Implantierungs-komplikationen; Versagen von Zahnimplantaten.

SPANISH / ESPAÑOLAUTOR(ES): Kelly Misch, DDS, Hom-Lay Wang, DDS,MSD, PhD. Correspondencia a: Hom-Lay Wang., DDS.,


MSD, PhD, Dept. of Periodontics and Oral Medicine, Uni-versity of Michigan, School of Dentistry, 1101 N. University,Ann Arbor, MI 48109-1078. Telefono: 734-763-3383, Fax: 734-936-0374, Correo electronico: [email protected] de la cirugıa de implante: Etiologıa y tratamiento

ABSTRACTO: Las complicaciones de la cirugıa de implanteson ocurrencias frecuentes en la practica odontologica y elconocimiento de la atencion de estos casos es esencial. Elobjetivo de este trabajo es destacar los desafıos en el trata-miento de complicaciones quirurgicas relacionadas con elplan, con la anatomıa y los procedimientos ası como explicarla etiologıa, atencion y opciones de tratamiento para lograr unresultado satisfactorio.

PALABRAS CLAVES: Implantes dentales; complicacionesdel implante; falla del implante.

PORTUGUESE / PORTUGUÊSAUTOR(ES): Kelly Misch Cirurgiao-Dentista, Hom-LayWang Cirurgiao-Dentista, Mestre em Odontologia, PhD.Correspondencia para: Hom-Lay Wang., DDS., MSD, PhD,Dept. of Periodontics and Oral Medicine, University of Mich-igan, School of Dentistry, 1101 N. University, Ann Arbor, MI48109-1078. Telefone: 734-763-3383, Fax: 734-936-0374,e-mail: [email protected] de Cirurgia de Implante: Etiologia &Tratamento

RESUMO: Complicacoes de cirurgia de implante sao ocor-rencias frequentes na pratica dentaria e o conhecimento dagestao desses casos e essencial. O objetivo desta revisao erealcar os desafios de complicacoes cirurgicas relacionadas aplanos de tratamento e a anatomia, bem como discutir asopcoes de etiologia, gestao e tratamento para alcancar umresultado de tratamento satisfatorio.

PALAVRAS-CHAVE: Implantes dentarios; complicacoes deimplantes; falhas de implantes.

RUSSIAN /!"#$%&: Kelly Misch, !"#$"% &$"'($")"*++, Hom-Lay Wang, !"#$"% &$"'($")"*++, '(*+&$%,+%-%*+./&#"0 &$"'($")"*++, , !"#$"% 1+)"&"1++.!"#$% "&' ()##$%*)+"$+,--: Hom-Lay Wang., DDS.,MSD, PhD, Dept. of Periodontics and Oral Medicine, Uni-

versity of Michigan, School of Dentistry, 1101 N. University,Ann Arbor, MI 48109-1078. .$&$/)+: 734-763-3383.,01(%: 734-936-0374, !"#$% 2&$(3#)++)4 *)536:[email protected]$'()*+,+-., /'01,2345-,'. 61- 7-1819-2,':);-<6(3+03=--: >0-)()9-. - (,2,+-,

%?@AB?. 2&)"34/4+5 6%+ ,+%-%*+./&#"0 +'6)(4-$(7++ 58)59$&5 .(&$:' 58)/4+/' 8&$"'($")"*+./&#"0 6%(#$+#/, 6";$"'- "./4< 8(34"=4($< '/$"!: >"%<>: & $(#+'+ &)-.(5'+. ?/)< ;$"*"">="%( — 6"#(=($< $%-!4"&$+ )/./4+5 ,+%-%*+./&#+,"&)"34/4+0, &85=(44:, & 6)(4"' )/./4+5, (4($"'+/0+ 6%"7/!-%"0, ( $(#3/ ">&-!+$< ;$+")"*+9, '/$"!:>"%<>: + 8(%+(4$: )/./4+5 !)5 !"&$+3/4+5-!"8)/$8"%+$/)<4"*" %/=-)<$($(.

CDAE?"&? FD$"!: =->4:/ +'6)(4$($:;"&)"34/4+5 6%+ +'6)(4$(7++; 4/-!(.4(5 +'6)(4-$(7+5.

TURKISH / TURKCEYAZARLAR: Diçs Hekimi Kelly Misch, Diçs Hekimi Hom-Lay Wang. Yazısma icin: Hom-Lay Wang., DDS., MSD, PhD,Dept. of Periodontics and Oral Medicine, University of Mich-igan, School of Dentistry, 1101 N. University, Ann Arbor, MI48109-1078 ABD. Telefon: 734-763-3383, Faks: 734-936-0374, eposta: [email protected] mplantolojide Profilaksi Amacıyla Antibiyotik Re-jimi: Nedenler ve Protokol

ÖZET: Oral implantolojide antimikrobiyal ilaç kullanımı,cerrahi yaradaki enfeksiyonları azaltır. Antimikrobiyal pro-filaksi, tüm Sınıf 2 (temiz-kontamine) cerrahi prosedürleriiçin endike olup, bunlara dental implantın bakteriyel kon-taminasyonu sırasında yeterli düzeyde kan bulunan cerrahiprosedürler ile kemik greft prosedürleri de dahildir. Antibiyo-tiklerin etkinlii açısından zamanlama ve doz, kritik önemtaçır. Antibiyotik genelde prosedür nedeniyle enfeksiyonasebep vermesi en olası olan bakteriye göre seçilir. Yazarlar,diç hekiminin uygun çekilde ilaç reçetelemesine yardımcıolmak üzere prosedüre, yerel konakçıya ve sistemik faktörleredayanan bir sınıflama ve protokol sistemi geliçtirmiçlerdir.

ANAHTAR KELMELER: dental implantlar, antibiyotikprofilaksi, cerrahi yara enfeksiyonu, farmakolojik protokol,risk faktörleri.


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Implant Surgery Complications: Etiology and · PDF fileImplant Surgery Complications: Etiology and Treatment Kelly Misch, DDS,* and Hom-Lay Wang, DDS, MSD, PhD† Surgical complications