PostSurgicalManagementIIImplantcomplications

TheodoraKompotiati10/28/2014

Intraoperativecomplicationsinimplantplacement

Incorrectimplantangulation

• Buccolingual angulation-Angulationof15degreesorlessisacceptable- Implantangulation≥25degreesmaycompromisesupportingbone

Mechanicalcomplicationsofoff-axisloading

• Restorationfracture• Retainingscrewfracture• Abutmentfracture• Implantbodyfracture• Osseousdestructionbecauseofunfavorableloading

• Plaqueaccumulationunderlargepontics

Ifanimplantcan’tbeplacedwithangulation≤15degreestheimplantshouldbeplacedinadifferentpositionorridgeaugmentationshouldbedonefirst

Mesiodistal angulation• Singleimplantcases-excessiveangulationshouldbeavoided

-useofangledabutmentscancompensateforslightinclinations

-checkangulationafterpilotdrill-radiograph

-Lindermann side-cuttingdrillcanbeusedtoadjustangulation

• Multipleimplantcases

-Mesiodistal inclinationhaslesserinfluenceonocclusal loadtransfertotheimplantbecausetheprosthesisredirectsocclusal forces

-Implantsurvivalrate93-97.5%

- Alternativetoridgeaugmentationorsinuselevation

Mal-alignment• Useofparallelpins

• Multipleimplants- checkangulationoffirstosteotomy,ifsatisfactorythenparallelnextosteotomytothefirst

• Whenanaturaltoothispresent,firstpilotdrillcanbealignedtolongaxisofthetooth

NerveInjury

• Localanestheticneedle• Laceratedbythescalpelduringincision• Stretchedduringflapreflection• Damagedbyosteotomydrills• Compressedduringimplantinsertion

ClassificationofnerveinjuryDay,1999

Neuropraxia:-mildinjurycausedbycompressionorprolongedtractionofthenervethatresultsinlossofsensation-intactaxons-sensationtypicallyreturns4weeksaftersurgeryAxonotmesis:-severecompressionortractionthatdamagestheaxonbyedema,ischemiaordemyelination-partialsensationreturnsin5-11weeksandsensationcontinuestoimproveoverthefollowing10monthsNeurotmesis:-lossofcontinuityoftheaxonanditsencapsulatingstructures-repairrequiresmicrosurgery-prognosisforfullyrecoveryispoor

Symptomsofnerveinjury

• Paresthesia:abnormalsensation• Hypoesthesia:reducedfeeling• Hyperesthesia:increasedsensitivity• Dysesthesia:unpleasant(painful)sensation• Anesthesia:completelossofsensation

Spontaneousreturnofsensationdependsonseverityoftheinjuryandthenerveinvolved

Preventionofnerveinjury• Detailedknowledgeofanatomy• CarefulTPLusingCTSCANimagesanddiagnosticwaxups

• Drillsstoppers• Surgicalguides• Carefulmanipulationofsofttissue

Implantsurgeonshouldusecommonsenseandavoidimplantplacementinareaswithhighpotentialforinjury

Inferioralveolarnerve

• BranchofV3• Foramenovale• Sensorybranches(auriculotemporal,lingual,inferioralveolar,buccal nerves)

• Motorbranches(musclesofmastication)

Injuryprevention• CTscanimagestodetermine

exactdistancebetweenthesuperiorborderofIANcanalandcrestal bone

• 2mmmarginofsafetybetweenapicalendoftheimplantandsuperiorborderofIANcanal

• Useofcomputer-generatedsurgicalguide

• Compensationforslightadditionallengthofthedrill(drilllength0.5-1mmlongerthantheimplantplaced)

• Usedrillstoppers

Mentalnerve

• Exitsthemandiblethroughmentalforamen

• Locatedbetweenapices1st and2nd premolar

• Sensationtochin,lowerlip,labialgingivaofmandibularanteriorteethandskinovermandibularbody

• Anteriorloop(traversesinferiorlyandanteriorlytothementalforamenbeforeturningbacktoexittheforamen)

• Implantshouldbeplacedatleast5mmanteriorlytomesialaspectoftheforamen(3mmtoallowfortheloopand2mmassafetymargin)

• Flapreleasingincisionsmesialtomentalnerveshouldterminatejustsuperiortothemucogingival junction

• Extensiveresorption-mentalforamenmaybelocatedatthecrestoftheridge

- Crestal incisionshouldbeplacedonthelingual

- FTFcarefullyreflecteduntiltheforamenisidentified

Mandibularincisivecanalandnerve

• IANsplitsintothementalnerveandtheincisivenerves

• Insomecasesatruecanalwithlargelumenispresent(0.48-2.9mm)extendinganteriorlyandinferiorlytothementalforamen,8-10mmfromthelowerborderofthemandible

Lingualnerve• BranchofV3• Sensoryinnervationtoanterior2/3ofthe

tongue

• Receivestastefibersfromthechordatympani(branchoffacialnerve)

• ItisanesthetizedduringIANblock

• Locatedmedialtothelingualcorticalplateofthemandible,belowthecrestoftheridgeandposteriorto3rdmolarroots

• Coveredbyathinlayerofalveolarmucosaandmaybevisibleclinically

• Miloro etal:Nervecrossesovertheretromolar padin10%ofthepatients

Preventionofinjury

• Placementofdistalreleasingincisionat30degreestowardthebuccal intheretromolarpad

• Carefulandgentlereflectionofthelingualflapintheposteriormandibularregion

• Avoidlingualreleasingincisions

Infraorbital nerve

• BranchofV2

• Infraorbital foramen

• Innervatestheskinbetweenthelowereyelidandtheupperlip

• Canbedamagedduringflapreflectionforlateralwindowsinuselevation

• Implantplacementinanteriorareaofhighlyresorbedmaxilla

• Preventionofinjury:-CTscanevaluation-flapreflectioninferiortotheforamen-gentlemanagementofthesofttissue-carefuluseofretractors

Managementofnerveinjuries• Ifthereisconcernthatnervedamagehasoccurredthe

situationshouldbeassessedsoonaftertheinjury

• Takect scantodetermineifalteredsensationisduetoimpingementbytheimplantorresultoftissuemanipulationoredema

• Iftheimplantisthecauseofthealteredsensationshouldberemoved

• Alteredsensationcanbeduetoinflammatoryreaction- 3weekcourseofanti-inflammatorymeds(Ibuprofen800mg)

• Theareaofdecreasedoralteredsensationshouldbeoutlinedindetail

• Lingualnerveinjuryissuspected- testtastesensationwithsaltandsugar

• IAN,mentalnerveinjury:sensitivityoflipandgingivacanbetestedbycottonswab,thermalsensitivitywithiceandwarmmirrorhandleandabilitytodistinguishdirectionofmovementwithasoftbrushonthelipandchinwitheyesclosed.

• Examinationshouldberepeatedafter1month

• Atthistimecompletelossofsensation,diminishingsensationorspontaneouspainaresignsthatnormalsensationisunlikelytoreturnspontaneously

• Refertomicroneurosurgeon

• Ifimprovementisnotedatfollowupappointments- follow-up4monthsbeforereferral

• 1998-2009:92Liabilityclaimsassociatedwithpersistentalteredsensationfollowing DIplacement

• 63%ofLCssubmittedbywomen

• 30LCswereissuedduring2nd post-opyearand15LCs>5years

• 4.4%submittedbypractitioner• 95.6%submittedbypatient

• 76%ofLCs- relatedtosx performedbasedonPAandPANO

24%ofLCs- relatedtooperations basedon CT

• 65%ofLCs- generalpractitioners,34%OMFSorPeriodontist

Inmostcasestheimplantlengthwasgreaterthantheavailableboneheight

Actionwastakenbythepractitionershortafterbeinginformed ofalteredsensationin52.2%ofcases

DIremovedin32.6%ofpatients,liftedin19.6%ofpatients

Management• ImmediateremovalofDIsuspectedtohavecausedthe

injury

• Misch andResnik:intraoperatively observedtraumatothenervemandatesthelocalintroductionofIVformofdexamethasoneintotheosteotomysite,followedbya6-dayregimenoforaldexamethasone

• Ifneurosensorydeficiencyreported- ≤1weekofsx:acourseofsteroidsfollowedby3-weeksof

NSAIDS- >2weeks:onlyNSAIDS

Curvedextractionsocket• Immediateimplantplacement

• Thickpalatal/lingualwallofthesocketdirectsthedrilltowardsthethinnerbuccal plate

• Perforationofthebuccal wallcanoccur

• UseLindermann bur

• Groovecutinthelingualwallfacilitatingdirectionofsubsequentimplantdrills

• Maxillaryanterior,mandibularpremolarandanteriorsites

Anotherwaytomanagecurvedsocket

• Pilotdrillatsharpangleintothelingualwallofthesocket

• Aspreparationproceedsapicallyanddrilldiameterincreases,severityofentryanglelessensandstraightosteotomyiscreated

• Shallowsocketsorwithdamagedbuccal plate(intactbuccal platewillprohibitdrillingattherequiredangle)

Injurytoadjacentteeth

• Placementofimplanttooclosetoatooth-canimpingeitsbloodsupply-overheatitssurroundingboneduringosteotomypreparation• Toothmaybecomenon-vital-endo therapy-apicoectomy-extraction

Symptoms

• Severepain• Swelling• Thermalsensitivity• maybeimmediateordelayed• Paradiolucencymaybepresentwithinshortperiodoftimeafterinjuryoccurs

Prevention• Carefulspaceassessmentoftheedentulousareausingct scan

• Minimumamountofbonebetweenimplantandadjacenttoothis1mm

• Ifspaceistoonarrow- Orthodontictreatment• Checkpositionafterpilotdrill• Computer- generatedsurgicalguides

Management

• RedirectionwithLindermann bur• Ifosteotomyisenlargedanditsredirectionisnotsatisfactoryimplantplacementmustbedelayed

• Ifpulpaldamageissuspectedpost-op:antibiotics+endo therapyimmediately

• Implantshouldberemovedifitappearstohavepenetratedtherootoftheaffectedtooth-developmentofanabscesscanaffectimplantosseointegration

Retainedroottipsattheimplantsite• PlacementofDIincontactwithroottipscanleadtoinflammation• Mayrequireimplantremoval• Gher-Vermino animalstudy-implantsplacedincontactorcloseproximitywithrootfragments- nosignsofinflammation• Buser etal,titaniumimplantsplacedinmandiblesofmonkeyswithretainedapical

rootfragments-histology: cementum ontheimplantandcollagenfibers insertedintocementum

Implantsshouldneverintentionallybeplacedincontactwithremainedroottips

Prevention

• CTscanshouldbetakentoidentifyexactpositionandsizeofroottip

• RemovalandGBR• Implantplacement2-4monthsafterroottipremoval

• Insomecasessimultaneousimplantplacementwiththeremovaloftheremainingroottipcanbeachieved

Ifroottipfoundpost-op• monitortheareaforsignsofinfection• administerantibiotics• Removeroottipandimplant• Removeroottip,excisionofinfectedtissuesandGBRinthebonydefect

Bleeding

• Thoroughmedicalhistory• CTscanevaluation

SofttissueBoneArteries

Softtissuebleeding• Mostcommonsigncontusionorbruise-petechiae <2mm-purpura 2-10mm-ecchymosis>10mm• Bruising:resultofintra-opandpost-opbleedingintothesofttissuespaces

(subcutaneous)adjacenttosurgicalsite• Gravitymaycausethebloodtotravelundertheskinalongfascial planes

tootherlocations(chest)• Olderpatients>50yearsold• Extensiveflap

Likelihoodandseverityofbleeding-pt’s systemichealth-flapsize-anatomyofthesite

Tominimizesofttissuebleeding:

• Avoidverticalreleasingincisions• Incisecleanly• Avoidcrushingortearingsofttissue• Smoothsharpbonyareas• Eliminategranulationtissue• Identifyandmanagesmallsofttissuearteries• Placesufficientsutures

Tocontrolsofttissuebleeding:

• Applypressuretothearea.Ifnotsuccessful,clampthevesselwithahemostatandligateitwithresorbable suture

• Askthepatienttobiteon2-inchgauzefor30min

• Controlbleedingpointswithelectrocautery

• Bleedingfromanextractionsocket-gelfoam absorbablegelatin-surgicel oxidizedregeneratedcellulose-topicalbovinethrombin-Heliplug cross-linkedcollagen

• Bleedingfromabonyartery-adjacentbonecanbecrushedintothebleedingorifice-bonewax-electrocautery

ArterialBleeding

• Greaterpalatine• palatatine/incisive• Lingual• Sublingual• Submental

Anteriorregionofthemandible

• Sublingual artery(branchofthelingual)

• Submentalartery(branchofthefacial)

Hemorrhagefromthefloorofthemouth

• Perforationoflingualplatewithrotaryinstruments• Elevationoflingualperiosteum• Flapmanipulation

-Onsetintraoperativeor4-6hrspost-op

Signs:swelling,elevationofthefloorofthemouth,protrusionofthetongue,respiratorydistress,excessivehematoma,inabilitytoswallow,profuseorpulsatingintraoralbleeding

Managementprotocol

• Atfirstsignofswellingatthefloorofthemouthcall911

• Usingonehandapplypressuretothesuspectedperforationsiteintraorallywiththethumbandextraorally withtheindexfinger

• Calmlyexplainthecomplicationtothepatient

• Forburiedbleedingvesselsattempttoligatethevesselbyapplyingpressureonthesourceofbleeding

Needleshouldenterthetissueabout6mmawayfromthevesselononeside,exit3mmawayfromitontheotherside,enterthetissue3mmfromthevesselontheoriginalsideandexit6mmawayfromitontheotherside,knot.

• Ifthebleedingvesselcanbeidentifiedandisolated,closeitslumenwithhemostatandplaceasuture

• Pullthetongueforwardagainstthehyoidbonetoreducebleedingfromthelingualarteryanditsbranches

• Ifinjuryistofacialarterypressthecommoncarotidarteryagainstthe4th cervicalvertebra

• Donotmakeincisioninthefloorofthemouthtorelievehematoma

• Iftheimplanthasalreadybeenplaced,donotremoveit

• Ifpt developsrespiratorydistressinsertaflexiblenasalairway

• Transferpt tonearbyhospital

Overheatingofboneduringdrilling• Bonecelldeathandresorption aroundtheimplant• ImpairsuccessfulosseointegrationRadiographically:radiolucencysoonaftersx

Erikssonetal:Bonetissuesensitivetoheatat47°CIrreversibleboneinjuryafter1minofexposureto53°CBonenecrosisattemperatures>60°C

Whenpropertechniqueandirrigationareusedtemperatureneverexceeds38.8°Cduringamaximumof5secondsofdrilling

• Usesharpdrills• Usecorrectdrillingsequence• UseanadequateamountofcoolantDrillinginmaxillamayrequireasecondsource

ofexternalirrigationtocompensateforcoolantlostduetogravity

• Useinandoutmotion(contactbetweenthedrillandthebone1-3sec)

• Inthepresenceofadequateamountofcoolant,sharpdrillsandproperdrillingtechniques,thespeedofthedrilldoesnotinfluencetheheatgeneratedattheosteotomysite

Treatmentoffailedimplantsduetooverheating

• Implantshouldberemovedandanynecroticbonedebrided

• Antibiotics,anti-inflammatoryandpainmeds

• Monitorarea• Bonegrafing andimplantplacementcanbere-attemptedafter3-4monthsofhealing

Strippingoftheimplantsite

• Densebone• Clinicianattemptstoseattheimplantdeeperthaninitialosteotomy

• Duringinsertionthetorquelevelsarehighandthenbecomesuddenlylow,strippinghasoccurredandimplantshouldberemoved

3options• Abandontheosteotomyandprepareanewsite

• Removelooseimplantandpreparedeeperosteotomyforlongerimplantifpossible

• Removetheimplantandplaceawideronewithoutenlargingtheosteotomy

Sinusfloorperforation• Ifperforationoccursafterpilotdrill(2mm),implantplacementprocedurecanproceedaslongassuccessivedrillsdonotcontactthesinusfloor

• Ifalargerdiameterhaspenetratedthesinusfloor,aborttheprocedure,placecollagendressingandobtainprimarysofttissueclosure

Prevention

• Carefulassessmentofpre-sx CTscan• Usedrillstoppers• Planforsinusaugmentation

Nasalfloorperforation• Bleeding• Pain• Swelling

-BoneaugmentationifnoadequateboneheightManagement:anti-inflammatory,antibiotics,nosmoking,noblowingnose,nocoughingwithmouthclosed

Displacementofimplantsintothemaxillarysinus

• Partialdisplacement-implantintrusionintothesinusifimplantislongerthantheavailablebone- Ctscanevaluation- Cautionwhenthereisadehiscenceintothesinusfloorapicaltotherootthatisextractedforimmediateimplantplacement

- Useshorterimplant/sinusaugmentation

• Completedisplacement- Canoccurduring implantplacementorlater

- Riskishigherwhenimplantsareplacedsimultaneouslywithlateralwindowsinuselevation

- Single stageapproach- atleast5mmresidualboneheight

- Displacementofimplantsintothemaxillarysinus:a)spontaneous expulsionofthemthrough theantrum intothenoseandthenoutthrough thenostrilsorthepharynx/oralcavityb)migrationoftheimplanttootherparanasal sinusesc)persistenceof implantintothemaxillarysinus

- Removal:• (FESS)endoscopic approachthrough nasal

cavity- Caldwell-Lucprocedure (intraoralapproach)

• 36healthypatients• Displacedimplantsintothemaxillarysinus

• Nosignsofacuteofchronicsinusitis• “Pediclebonywindowtechnique”

Biglioli,Chiapasco 2013

• Drawoutlineof thewindow

• 2pairsofholes,2overtheinferiorborder, 2below

• 2verticalandlowerhorizontalosteotomy:bone+membraneupperhorizontal:onlybone

• Windowrotatedinwardsoroutwards

• Implantremovedwithsuctioning tip

• Rinsewithsterilesaline

• Resorbable suturesthroughthecreatedholestoreposition thewindow

• CTscantaken4-6monthsaftersurgery-correctstabilizationofthewindow• Vascularizationprovidedbysinusmucosaensuresthesurvivalofbonywindow

• Shortoperatingtime20-30min• Quickhealing

DisplacementofdentalimplantintoMaxillaryincisivecanal

• Penetratingthecanalwillcompromiseosseointegration becauseofepithelialtissuefound inthecanal

• Incisiveforamen-meandiameter4.6mm

• Nasopalatine nerveandanteriorbranchofthegreaterpalatinenervemeetattheincisiveforamen

• Greaterpalatineartery

• Iordanishvilli:distancebetweenincisiveforamenandrootsofanteriorteethis3.5mm

• Boneresorption togetherwithenlargedforamenmaychallengeimplantplacement

Graftingoftheincisivecanal

• Excisionofnervesandbloodvesselsoftheincisivecanal,bonegrafting,immediateordelayedDIplacement

• Nerveandarteryoftheincisivecanalanastomosewithgreaterpalatinenerveandarterypermittingrevascularizationandgradualre-innervationoftheregionwithin3-6months

• Possiblelossofsensationintheanteriorpalate-pt shouldbeinformed

Nasopalatine ductcystdelayedcomplicationtoimplantplacement

• Developmental,epithelial,non-odontogenic cyst

• 1%ofpopulation• Radiographically canbe

mistakenforendodonticlesion• Radiolucencyapicaltocentral

incisorteeth• Averagediameteris1.5cm• Epithelialremnantsofthe

nasopalatine duct• Midlineofanteriormaxilla• 4th,6th decades• Slightmalepredominance• Asymptomatic(advancecases

pain)• Swellinganteriorpartofpalate

McCrea2012

• Ctscan:extentofinvolvementofneighboringanatomicstructures

• Sx:-smallswellings:marsupialization-largeswellings:marsupialization,cystectomy,bonegrafting

• Ifnotdiagnosedearlycanexpandthroughthebuccalandpalatalwalls

Aspirationoringestionofforeignobjects

• Drills• Screwdrivers• ParallelpinsAspiration-coughing,choking,decreasedbreathsounds,wheezing,cyanosis-patientsmaybeasymptomaticinitially-referforchestradiograph-CTscanvirtualbronchoscopyIngestion-infection-GIblockage-sharpobjectscanerodethethinesophagealwallandcausedeadlycomplications

Prevention

• Smallinstrumentsshouldbetiedwithfloss

• Largepieceofgauzetoshieldtheairway

Mandibularbonefracture• Rarecomplication• Placementorremovalofimplantsinseverelyresorbed

mandibularbonePrevention:- TPLinseverelyresorbedmandible,increasein#ofimplants

willincreasetheriskoffracture- CTscanevaluation- Attentiontobonedensity(pts withosteopororis)- Ridgeaugmentationproceduresbeforeimplantplacement- Avoidexcessivetighteningofimplantsduringplacement- Usingshortabutmentstominimizestressonimplants- Softdietduringhealingperiodtolimitstress

• Symptoms-pain-swelling-presenceorabsenceofmobilityinthemandible-changeinocclusion-fracturewithnohistoryoftrauma

• Management-clinicalandradiographicexamination-anatomicalreductionandimmobilizationofthefracturedsite-restorationofocclusion-applicationofstablefixationü Minimallydisplacedfractures:Externalfixationdevice(acrylicsplint,denture)ü Stainlesssteelreconstructiveboneplates,screwretainedblockgraftsto

bridgenonunionfracturedareas,splints,maxillomandibular fixation

-extractionofdiseasedteethwithinthefractureline-monitorhealing,softdiet,limitjawmovements

Shouldtheimplantatfracturelineberemoved?

• Notnecessaryiffixationcanbeachieved• Avoidexposureormovementoftheimplantduringreductionofthefracture

• Additionalhealingtimeshouldbeprovided• ImportanceoftheimplanttotheoverallTPL• Presenceorabsenceofinfection• Mobilityorimmobilityoftheimplant

Boffano etal,2013Mandibularfracturesandimplant

placement-Atrophicmandible-DuringImplantplacement,orimplantfailureandsubsequentosteomyelitis-Higherincidence infemales-Meanage57.9years-Mandibularsymphysismostfrequentsite-Mostfracturesoccurred3-6weeksor3monthsafterimplantplacement-openreductionreductionandinternalfixationmostfrequenttx option-softdiet

Deepimplantplacement

• Idealpositionis3mmapicaltoidealfreegingivalmargin(1-2mmbelowtheCEJofadjacenttooth)

• Deeppositionoftheimplant- deeperpositioningofimplant-abutmentmicrogapBoneresorption-softtissuerecession(thin

biotype)- pocketformation(thickbiotype)

Deepplacement

• Bonelossaroundtheimplantneck• Increasecrown/implantratio• Increasedcrownheight- increaseocclusal forces• Increasedsulcusdepth• Compromisedesthetics:boneloss- decreasedpapillafill

• Difficultyseatingprostheticcomponents• Difficultyremovingexcesscement

Shallowimplantplacement• Exposureofcoverscrewduring

healing

• Pooremergenceprofile-noadequatetissuethicknessovertheimplantplatform

• Decreasedcrownheight

• Exposureofimplantbody

• Bone/softtissuegrafting,implantremoval

Implantfracture• Intraoperative- Smalldiameterinternalheximplantsmoreprone

- WhenplacingimplantsintypeIandIIboneprecisepreparationoftheosteotomytodecreasetorqueatimplantplacement

- Useoftrephinedrillstoremovetheimplant

• Post-operative-occlusal overload-bruxism/clenching-cantileverforces- Prematureloading- Prosthesiswithoutpassivefit- Poorprostheticdesign

Removetheimplantwithtrephine,grafttheareaandplacetheimplantafter3-4months

Walia etal,Implantabutmentscrewfracture

• Morefrequentinposteriorregion• Morefrequentinpartiallydentatetocompletelyedentulouspatients

• Primaryreason:undetectedscrewloosening,ill-fittingsuperstracture oroverlaoding

Casereport• Occlusal accessholethrough thecrownto

accessthescrewheadandretrievethecrownalongwiththeabutment

• Finetaperedcarbideburwasusedtomakeanotchontheocclusal surfaceoftheabutmentbetweencenterof thescrewanditsperiphery

• Ultrasonicscaler tipwasengagedtothenotch

• Tipofscalerwasmovedcounterclockwise

• Brokenpartwasretrieved• Leverarmaround thecentralaxis

-torque=lengthofleverarmxforce-thegreaterthelengththelesstheforce

Excessivetorque-Bonenecrosis

• Excessiveinsertiontorque-bonecompressionbeyondphysiologictolerance-ischemia-necrosis

• Crestal regionmoresusceptibletonecrosis-corticalbone-decreasedbloodsupply

• Bonenecrosiswillappearwithin1st monthafterplacement

• Optimumleveloftorque-20-45Ncm

• Highdensitybone:-morepronetonecrosis-no>45Ncmtorque-followdrillingsequence-tappingdrills

• Lowdensitybone:• Omitfinaloneortwodrillsinthedrillingsequence,notappingdrill

• Useosteotomes tocondensebonelaterallythanremovingbone

Inadequateinitialstability• Overpreparation ofthesitewithexcessiveinandoutmotionsduringdrilling

• Useofdensebonedrillsinlow-densitybone• Followinganellipticalorimprecisepathwayduringdrilling

Management:-Looseimplantsshouldberemovedandreplacedbyawiderorlongerdiameterimplant-Abandonosteotomyandmakeanewoneifpossible- Abortprocedure,graftandplaceimplantlater

Kim,2012Subapical osteotomy(SAO)

• Onlycasereports• Riskofbonenecrosisandfailureoftheimplants

• Post-opvitalityinteethwithinandadjacenttobonesegmentisanothersignificantconsideration

• Implantsurvivalandchangesinbonetoimplantcontacthavenotbeeninvestigated

Post-operativecomplications

Pain• Painatitsmaximum1daypost-sx• Inflammation- 48hrspost-sx• Limitactivitiesforthefirst3daysaftersx• Properhandingofsoftandhardtissuetominimizepain

• Delayedwoundhealing:infection,incisionlineopening,smoking,malnutrition,aging

• Post-oppatientshouldstartantibioticsandanti-inflammatorymeds(ibuprofen,dexamethasone)

• Post-opcompliance(nosmoking,goodOH,takemeds,icepack,softdiet)

Incisionlineopening• Increasestheriskofinfectionatthesurgicalarea• Prevention-midcrestal incisionnotbuccal orlingual,moretensionfromlips,cheeksortongue-nosmoking-propersuturingtechnique(every3-5mmalongtheincisionline,needlepenetrating3mmfromtheincisionline)-non-tensionflapclosure

Flapreleasingtechnique• Scoretheperiosteum

layeroftheflapwithsharpblade(1-3incisions)

• Ifnotenoughrelease-musclelayerrelease

-insertclosedblunttipscissorsintothescorelines-openthescissorswithinthemusclelayerandclosebeforeremovingthem

Prevention

• Relievepressureofprosthesis• Medstominimizeswelling• Donotraisetheliptolookthearea• Icepacks• Softdiet

Treatment

• Ifincisionlineopeningisminornoattempttoclose,healingbysecondaryintention

• GoodOH,rinsewith0.12%CHXtwice/day

Coverscrewexposure• Higherriskofimplantinfection• Etiology-pressurefromprosthesis-thintissue-shallowimplantplacement-immediateimplantplacementinextractionsite

Management• Partiallyorcompletelyexposure- recoveringmaynotbenecessary

• Identifyfactors- Interimprosthesismustberelieved• Moreclosefollow-upappointmentstomonitorforpotentialinfection

• Checkscrewforlooseness,rinsewithPeridex• Hygienecompliance:gentlebrushingandPeridexathome

• Softfood(nopressure)

VanAsshe,2008Earlyperforationofcoverscrews-

marginalboneloss

• Retrospectivestudy

• 60AstraTechmicrothread implants

• Partiallyedentulousjaws

• 202-stageexposed,202-stagesubmerged,20one-stage

• X-rays:afterabutmentsx for2-stage,after3-monthsfor1-stage

• Boneloss- 2-stageexposed:1.96mm- 2-stagesubmerged:0.01mm- 1-stage:0.14mmOnecouldconsiderplacingahealingabutmentassoonasperforationisnoticedtopreventfurtherbonelossNeedstobeclinicallyconfirmed

• Non-perforatedmucosacoveringsubmergedimplantswascomparedtomucosafromedentuloussitestreatedwithnon-submergedimplants

• Non-perforatedmucosacoveringsubmergeimplants:

-inflammatoryfibro-epithelialhyperplasia

-mineralizedmaterialintheconnectivetissue(mostlysequestra)

-epithelialwidth1.5timeshighercomparedtocontrols

-inflammatoryinfiltratealmostdouble

• Bonedebrisproducedduringosteotomycancausechronicinflammatorycellinfiltrationas-well-asepithelialcoveringreaction

• Researchonperforatedsitesneededtobedone

• Noconclusionscanbemade

Bonegrowthoverthecoverscrew

• Removebonetoallowremovalofcoverscrew• Properseatingofhealingabutment• Careshouldbegiventoavoiddamageofimplantplatform

• Curettes,smallhandchisels• Afterplacementofhealingabutmenttakepatoensurethatnogapexists

Berglundh,2012Systematicreview-Implantcomplications

• Follow-upperiodatleast5years• 51studiesincluded• Edentulous/partiallyedentulous• Singlecrowns,fixedpartialandcompletebridges,overdentures• Implantlosspriortofunctionalloading- 2.5%• Implantlossduringfunction--2-3%ofimplantssupportingfixedrestorations->5%ofimplantssupportingoverdentures areexpectedtobelostduringa5-yearperiod• 1-2%incidenceofpersistingsensorydisturbance>1yearpost-sx• Softtissuecomplicationshigherinpatientswithoverdentures• Implantfracture<1%ofallimplantsduring5years• Complicationsinimplantcomponentshigherinoverdentures

• Overallsuccessrate- 99.5%forprostheses- 98.1%forimplants• 1.1%ofimplantsfailedbeforeprosthesisconnection• 0.6%ofloadedimplantswerelostthefirstyearoffunction• ImplantFailures:Maxilla2.9%,Mandible0.4%• 2maxillaryfixedprostheseswerereplacedbyoverdentures• Noneofthemandibularprosthesesfailedcompletely• Mostcommonproblemwithprosthesis-maxilla:speechproblems31.2%-mandible:lip-cheekbiting(6.6%)• Fractures-14%ofmaxillaryprostheses-1.7%ofmandibular• Gingivalproblems:1.7%oftheimplants

MoreproblemsinmaxillaTorsten 1991

Esposito,1999• Clinicallylackofosseointegration –implantmobility• Amobileimplantisafailedimplant• Animplantthatisprogressivelylosingitsboneanchorage

butisstillclinicallystable- failingimplant• Biologiccomplications:peri-implantmucositis,hyperplastic

mucositis,fistulae-Nolossofsupportingbone• Mobileabutmentvs mobileimplant• Implantcomplications:infection,impairedhealing,

overload• Treatmentofcomplicationsoffailingimplants-Leave

patientwithfunctionalrestorationandacceptableesthetics

Complications• BeforeprosthesisplacementWounddehiscence,persistentpain,swelling,fistuladuringsubmergedperiod

Softtissueorbone?Clinicalandradiographicexamination

Softtissue:residualsuturematerial,notfullyseatedcoverscrews,prematurewearingofthedenture,notadequaterelief

Bone:presenceofradiolucentlinesurroundingtheimplant,peri-implantapicalradiolucency

Peri-implantapicalradiolucency:a) Asymptomaticorpain/fistulaswellingb) Inactivevs active-inactive:residualbonecavitycreatedbyplacingshorterimplantsthanthedrilledimplantsite/heatinducedasepticnecrosis-active:bacterialcontamination

• AfterprosthesisplacementPatientshouldbeenrolledinmaintenanceprogramSofttissueconditionsOcclusionProsthesisstabilityRadiographsIncaseofbonelossandperi-implantradiolucencyremoveprosthesistoinspectimplant

• Patientsshouldbeadvisedtoreportimmediatelyanyadversesymptomssuchaspain,sensitivityonpressure,swelling,pus,mobility

• Therapyofinfectedfailingimplantshouldbeimmediate,aggressiveandcombined(systemicorlocalantibioticsandsurgicaldebridement)

References• PartIIIntraoperativeComplicationsinImplantPlacement.pp 20-89.Surgicalcomplicationsin

oralimplantology:etiology,prevention,andmanagementLouieAl-Faraje.QuintessencePub.,c2011.

• PartIIIPostoperativeComplications(complications30-33).pp 96-105.Surgicalcomplicationsinoralimplantology:etiology,prevention,andmanagementLouieAl-Faraje.QuintessencePub.,c2011.

• Froum,Klokkevold, etal.Implant-RelatedComplicationsandFailures.(CH77).pp 723-Carranza’sClinicalPeriodontology;Newman,Takeietal.,2012,11thedition,Elsevier.

• Jemt,T:Failuresandcomplicationsin391consecutivelyinsertedfixedprostheses supportedbyBranemard implantsinedentulous jaws:Astudyoftreatmentfromthetimeofprosthesisplacementtothefirstannualcheck– up.Int JOralMaxillofac Impls.6:270-276,1991

• Berglundh,Tetal:Asystematicreviewoftheincidenceofbiologicalandtechnicalcomplicationsinimplantdentistryreportedinprospectivelongitudinalstudiesofatleast5years.JClin Periodontol.2002;29suppl 3:197-212

• Esposito,Metal:Differentialdiagnosisandtreatmentstrategiesforbiologiccomplicationsandfailingoralimplants:Areviewofthe literature.Int JOralMaxillofac Impls 14:473-490,1999

• Biglioli F,ChiapascoM.Aneasyaccesstoretrievedentalimplantsdisplacedintothemaxillarysinus:thebonywindowtechnique.Clin OralImplantsRes.2013Sep30.[Epub aheadofprint]

• LevineRA.SoftTissueAugmentationProceduresforMucogingival DefectsinEstheticSites.Int JOralMaxillofac Impls 29(supplement)155-185.

• Tal,H:Spontaneous earlyexposureofsubmerged implants IClassificationandclinicalobservations.JPeriodotnol 7o:213-219,1999

• Asshe,Netal:Correlationbetweenearlyperforationofcoverscrewsandmarginalbone loss:Aretrospectivestudy:JClini Periodontol 2007:35:76-79

• KimA,Kar K,etal.Subapical osteotomytocorrectdentalimplantmalpositioningandverticalridgedeficiency:aclinicalreport.JProsthet Dent.2012Oct;108(4):204-8.

• McCreaSJ.Nasopalatine DuctCyst,adelayedcomplicationtosuccessfuldentalimplantplacement:Diagnosisandsurgicalmanagement.JOralImplantol.2012Mar12.[Epub aheadofprint]

• Givol N,Peleg O,etal.Inferioralveolarneurosensory deficiencyassociatedwithplacementofdentalimplants.JPeriodontol.2013Apr;84(4):495-501.

• Walia MS,Arora S,Luthra R,Walia PK.Removaloffractureddentalimplantscrewusinganewtechnique:acasereport.JOralImplantol.2012Dec;38(6):747-50.

• Boffano P1,Roccia F,Gallesio C,Berrone S.Pathological mandibular fractures:areviewoftheliteratureofthelasttwodecades.DentTraumatol.2013Jun;29(3):185-96.

Thankyou