Your SlideShare is downloading. ×
Implant Surgery Complications: Etiology and Treatment
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Saving this for later?

Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime - even offline.

Text the download link to your phone

Standard text messaging rates apply

Implant Surgery Complications: Etiology and Treatment

5,221
views

Published on


0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
5,221
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
158
Comments
0
Likes
1
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Implant Surgery Complications: Etiology and Treatment Kelly Misch, DDS,* and Hom-Lay Wang, DDS, MSD, PhD†S urgical complications during Implant surgery complications are complications as well as to discuss the implant placement are not un- frequent occurrences in dental practice etiology, management and treatment op- common. According to a retro- and knowledge in the management of tions to achieve a satisfactory treatmentspective study by McDermott et al,1 these cases is essential. The aim of this outcome. (Implant Dent 2008;17:159–677 patients (2379 implants) were in- review was to highlight the challenges of 168)vestigated, and an overall frequency of treatment plan-related, anatomy- Key Words: dental implants, implantcomplications was 13.9%. Operativecomplications made up a mere 1% of related, and procedure-related surgical complications, implant failuresthe overall, whereas inflammatory andprosthetic complications were 10.2%and 2.7%, respectively. Complications and relative risk factors. For example, should be noted that computer-aidedare expected and can lead to a number an 11 year retrospective study done by guides,4,5 made with no channel (eg,of poor treatment outcomes. The aim Moy et al,2 showed relative risk ratios vacuum-formed matrix) and only a hole,of this article was to address the etiol- (RR): increasing age (60 –79 y/o) had do not merit angulation guidance.ogy, and emphasize the potential prob- a strong association on risk with im- Mandibular teeth in the naturallems as well as, basic treatments that plant failure (RR 2.24), as well as dentition are lingually inclined in re-occur during the surgical phases of smoking (RR 1.56), diabetes (RR lation to both the mandibular base,6implant treatment. Complications can 2.75), head and neck radiation (RR specifically as 109 degrees,7 as well asbe outlined in 4 categories (Fig. 1): 2.73), and postmenopausal estrogen the maxillary opposing arch dentitiontreatment plan-related, anatomy- therapy (RR 2.55). (eg, lingual cusp buccal inclinatio-related, procedure-related, and other. n)and therefore implants should be Wrong Angulation placed at a similar inclination. FailureTREATMENT Implant angulation is yet another to do so may result in perforation ofPLAN-RELATED COMPLICATIONS determinant for implant success. the lingual concavity, constriction of Proper angulation should be determined the lingual space or damage of the Well organized, thorough treat- lingual artery. Restorations may be according to the future prosthesis with thement plans lead to successful implant difficult to restore due to tongue consideration of bucco-lingual, apico-treatment and patient satisfaction, impingement or incorrect opposing coronal, and mesio-distal positions.which are the ultimate long-term positions. In the posterior mandible, To place implants based on availablegoals. Patient selection is one of the limited mouth opening prevents the bone often results in poor esthetic out-most important determinants of suc- drill and implant carrier from fitting comes as well as long-term biome-cess or of failure. Implant treatment correctly in the vertical direction. chanical instability. Although, thereplanning should begin with reviewing Teeth adjacent to implant sites and are many “rescue techniques” for re-pertinent medical history information surgical guides with long drill chan- storing cases placed outside of the oc-and identifying any possible contrain- nels, often require the use of drill ex- clusion (eg, having to be with customdications to anticipate problems before tensions and maximum opening by the and angled abutments), the surgerythey occur. Predictability of implant patient which may be strenuous. Short should be planned for suitable angula-success can be jeopardized by absolute breaks to relieve muscle tension, using tion at the onset. Surgical guides can help control the implant placement a bite block and having the patient angle if they are made and used cor- shift their jaw to the opposite side can*Periodontics Resident, Department of Periodontics and OralMedicine, School of Dentistry, University of Michigan, Ann rectly. Choi et al3 investigated the help ensure the correct angulation ofArbor, MI.†Professor and Director of Graduate Periodontics, Department effects of dimensional factors of the the drill.of Periodontics and Oral Medicine, School of Dentistry,University of Michigan, Ann Arbor, MI. surgical guides on implant placement Yet another type of problem lead- and found that the length of the guide ing to incorrect implant angulation isISSN 1056-6163/08/01702-159Implant Dentistry channel was the primary factor in re- the use of a finger rest while drillingVolume 17 • Number 2Copyright © 2008 by Lippincott Williams & Wilkins ducing angle deviations in the mesio- (Fig. 2). Dentists have traditionallyDOI: 10.1097/ID.0b013e3181752f61 distal and bucco-lingual direction. It been taught to stabilize their hands by IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 159
  • 2. Treatment Plan Related Wrong angulation Improper implant location Too close Too far apart Lack of communication Anatomy Procedure Implant Related Related Complications Nerve injury Lack of primary Bleeding stability Cortical plate Mechanical perforation complications Sinus perforation Mandibular fracture Devitalization of Ingestion/aspiration adjacent teeth Fig. 2. Example of using a finger rest. Other Fig. 3. Implant positioned too buccally. Iatrogenic Human error ing multiple implants. For example, Tarnow et al9 demonstrated in a retro- spective study assessing 36 patients,Fig. 1. Outline of common complications during implant surgery. that an implant placed 3 mm away from an adjacent implant can have ad- equate stability and function but mayplacing a finger on adjacent teeth or implants to prevent horizontal bone later result in lateral bone loss. Yetthe chin while using instruments/ loss as well as to preserve esthetics.9 another issue to keep in mind whenhandpieces during periodontal and op- Preoperative measurements and plan- placing the implant is to measure theerative work to stabilize the hand as ning are essential to achieve an ideal vertical distance between the base ofwell as to reduce the muscle fatigue, implant placement that facilitates the prosthetic contact point and thebut implant dentistry is different. Due future implant prosthesis. Placing an crestal bone. Tarnow et al10 found thatto the length of implant drills implant in the wrong location is a frus- if the distance was 5 mm or less, 98%( 10 20 mm), using a finger rest trating, embarrassing and avoidable of the time the embrasure space filledwhile drilling, results in an inclination complication (Fig. 3). Measurements in, but as the distance increases to 6of the drill towards the hand that is (eg, interocclusal, interdental, ridge and 7 mm, the presence of a papillasteadied. Hence, using finger rests is height, and ridge width) confirm reduces to 56% and 27%, respectively.an ergonomic principle that should not whether implants are indicated in the de Oliveira et al11 found that as long asbe used for implant placement. first place. The spatial orientation 5 mm distance is maintained between Surgical guides and proper treat- should be in line with the occlusal contact point and alveolar bone crest,ment planning can alleviate angulation plane and centered according to the it does not make a difference in papillaproblems, but even so, angled abut- opposing occlusion to prevent cross- formation or bone loss, whether thements are hot selling items because bites or additional stresses on the pros- adjacent implants are 1, 2, or 3 mmclinicians are failing to abide by this thesis. Many times fixtures are ideally apart from each other.12important principle. The development of intended for one specific position to beangled abutments has been a rescue in the proper occlusion (Fig. 4). If Lack of Communicationtechnique for these wrongly placed im- more than one implant is to be placed, An informed consent form is anplants and allows for a more successful a diagnostic wax-up should be used to excellent way of communicating po-esthetic outcome. In summary, use a determine the correct implant loca- tential surgical risks and complica-surgical guide with a long channel that tions. At the very least, drawing and tions to a patient. Common problemsdoes not give leeway to veer and com- measuring on the stone casts will al- to address include but are not limitedmunicate with the restorative doctor. low for calculations and treatment to postoperative infection, bleeding, planning. swelling, facial discoloration, tran-Improper Implant Location Hypothetically, a surgical compli- sient pain, paresthesia, neuralgia, frac- Adjacent teeth should be at least cation could also occur, but not be ture, joint pain, muscle spasm, tooth1.5 mm from the implant body8 and realized by the surgeon at the actual looseness and sensitivity, recession,more than 3 to 4 mm between adjacent time of surgery, especially when plac- speech change, trismus, and swallowing160 IMPLANT SURGERY COMPLICATIONS
  • 3. gets longer as the implant diameter gets wider), where it ranges from 1 mm (3.4 mm drill) to 1.45 mm (4.85 mm drill) as well as 1 mm thickness of cortical plate above the mandibular ca- nal (unpublished data). Bartling et al21 observed 405 man- dibular endosseous implants placed in 94 patients to determine the incidence of altered sensation using standard neurologic tests over a 6-month pe- riod. An incidence of 8.5% was found at the first postoperative appointment. Only 1 patient experienced complete anesthesia for 2 months. This was later resolved by 4 months. Unique to thisFig. 4. Example of a poor initial treatment plan. No. 19 implant (a) was placed too far from the study was that no permanent altered sen-second premolar causing the fixed crown to be cantilevered mesially to obtain contact with the sation was found for any of the subjectsadjacent 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 2 over the 6 months. Van Steenbergheadditional implants to alleviate complications. et al,22 also reported a similar incidence rate of 6.5% for altered sensation at 1 year after mandibular implant place-of foreign objects. Should a complica- treatment planning must be done to ment. In contrast, other studies havetion occur during the post operative ensure complete aversion of the infe- reported higher rates. Ellies andhealing time, it is recommended to rior alveolar, mental, incisive or lin- Hawker23 found an altered sensationgive emergency contact information gual nerves. If the mandibular canal incidence of 36%, of which 10% toas well. cannot be seen on a panoramic radio- 15% of those patients never regained In the United States, 12.1% of graph, a computer tomography (CT)medical malpractice payment reports sensation. scan should be taken to verify the lo-were against dentists in 2002.13 In den- cation. The potential risks and compli- Radiographs should be taken iftistry, the main causes for lawsuits are cations of injury or damage to these the surgeon has any doubt about whereactual body injury (eg, loss of sensa- vital structures should be included on the drill is or if the drill or implant istion, oroantral fistula, life-threatening the informed consent to avoid liability in close proximity to or invading, neu-bleeding) and major disappointment.14 in cases of lawsuits. ral anatomical structures. If the situa-This could be avoided if a patient Possible causes of nerve injury in- tion is the latter, the implant needs tounderstands the fundamentals of the clude poor flap design, traumatic flap be removed, or a shorter body implantsurgical procedure and what is to be reflection, accidental intraneural injec- should be placed instead. Within daysanticipated. A valuable tool used to tion, traction on the mental nerve in an or months, minor trauma injuries usu-communicate between surgeons’ and elevated flap, penetration of the os- ally heal but permanent damage fromrestorative doctors is a surgical guide. teotomy preparation and compression neuritis can occur. Treatment optionsThe sole purpose of fabricating the of the implant body into the canal. include neuronal anti-inflammatoryguide is to identify the correct location To circumvent trauma to the infe- drugs such as clonazepam, carbamaz-and angulation for implant placement rior alveolar nerve (IAN), some clini- epine or vitamin B-complex,24 al-which will undoubtedly reduce/elimi- cians suggest local infiltrating instead though marginal effects have beennate unnecessary surgery/prosthetic of a mandibular nerve block. This idea shown. Referral and treatment for IANcomplications. Surgical guide designs is a safety precaution to avoid having injuries should be done immediatelyinclude the labial outline surgical the drill approach too close to the ca- before distal nerve degeneration de-guide fabricated from a wax arrange- nal.19 Overpenetration occurs when velops.25 According to Hegedus andment of the intended definitive restora- the cortical portion of the alveolar Diecidue,26 follow-up appointmentstion,15 a clear vacuum-formed matrix,16 a crest puts resistance on the drill, but as should take place at 4, 8, and 12 weeksduplicate of the existing restoration,17 it enters the marrow spaces, it drops after placement and each visit shoulda light-polymerized composite mate- into the neurovascular bundle. Worth- include documentation of subjectiverial and drill blanks with a diagnostic ington20 investigated penetration into symptoms, oral/facial function andcast,18 as well as many other methods. the IAN canal in human cadavers and atrophic/cutaneous changes. The pa- recommended reviewing radiographs tient should then be referred for mi-ANATOMY-RELATED before surgery using the correct mag- crosurgery if total anesthesia persists,COMPLICATIONS nification as well as, allowing a 1 to 2 or if after 16 weeks, if dysesthesia isNerve Injury mm safety zone. This distance is to on-going.24,27 Timely referral for mi- When placing implants in the accommodate the Y dimension of the croneurosurgery is necessary to re-mandible, proper radiographs and pre- drill (apical extent of the tip which establish nerve continuity, improve IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 161
  • 4. sensation and motor skills and to pos- traumatic dental extractions can causesibly relieve pain.26 markedly thin plates or concavities, as well as overall ridge width deficiency.35Bleeding When preparing osteotomy sites or Life-threatening events associated placing implant fixtures in areas withwith dental implants are rare but major minimal labial plate thickness, or ifcomplications such as severe hemor- the implant is placed too buccally, arhage are more common and Goodacre fenestration or dehiscence implant de-et al,28 found hemorrhage-related im- fect is a common finding. A fenestra-plant complications had an incidence tion leaves intact bone coronally withof 24%. Potential causes include inci- the exposed threads at the apical por- Fig. 5. Implant placed into the maxillary sinus.sion of arteries in soft tissue, osteot- tion of the crest, whereas a dehiscenceomy preparation, and lateral wall sinus defect has the coronal portion of thelift procedures. implant exposed. Tinti et al,36 further (Fig. 5)? Jung et al42 reported the risk Kalpidis and Konstantinidis29 re- classified these defects as Class I if the of maxillary sinus complications inported a case involving a perforation implant was within the envelope of implants which penetrated the boneof the lingual cortical plate during an bone and Class II if it was left staying and mucous membrane of the sinusimplant osteotomy preparation of the outside the envelope. Immediate cor- floor at 2, 4, and 8 mm extensions.first mandibular premolar position. A rection with particulate bone grafting After 6 months, radiographic and his-critical hemorrhage and multiple he- with or without a membrane during tologic examinations did not show anymatomas immediately occurred after the time of implant placement, can be signs of pathologic findings in theperforation which was verified by a done as long as primary stability has maxillary sinus of the 8 dogs. DespiteCT scan. been achieved. “Flapless” implant sur- the convincing results, the question re- Risk sites30 as described above in geries should be avoided in areas of mains whether 6 months is a longthe posterior mandible include the potential perforation of the buccal or enough follow-up period. Hence, itsublingual fossa and lingual cortex. A lingual bone. has been suggested that simultaneousruptured artery in the area within 30 implant placement during sinus liftminutes, can cause a blood loss rate of Sinus Membrane Complications procedures is not considered a contra-14 mL/min31 and if 500 mL of blood In the maxillary posterior, the indication or less predictable proce-loss occurs, hypotension can result.32 proximity of the sinuses37,38 can create dure. Nonetheless, careful planningLife-threatening airway obstruction is a problem for dental implants if there and precise surgery execution are es-a serious threat and early treatment is is minimal residual crestal bone ( 5 sential to avoid any potential sinusessential. Treatment involves having mm) for stability. The maxillary sinus complications.the patient stick out their tongue to lift technique is an accepted proce- Lastly, losing an implant into thecompress the blood vessels against the dure, demonstrated by Tatum,39 to maxillary sinus is a relatively uncom-body of the mandible. Placing pres- augment vertical height in the severely mon surgical complication. However,sure with gauze in the sublingual area resorbed posterior maxilla area to fa- in cases with less than 5 mm of bone,does not work as one would intuitively cilitate proper implant placement. Si- mastication can cause the implants tothink. Extraoral pressure to the sub- nus complications often occurred move during the graft maturationmental or submandibular arteries for when the membrane is perforated at timeframe.43 Transantral endoscopic20 minutes against the body of the time of surgery. Ardekian et al40 found surgery is a reliable, minimally inva-mandible helps.33 maxillary sinus membrane perfora- sive method for retrieving displaced The posterior superior alveolar tions were more common in areas with objects from the maxillary antrumand infraorbital arteries are located minimal amount ( 5 mm) of residual with minimal complications,44,45 but itapproximately 19 mm above the max- alveolar bone but this did not affect does require having an endoscope or aillary alveolar ridge,34 and the anasto- the overall implant success rate. No referral to an ENT or oral surgeon.moses of these arteries can pose a risk statistical differences were found be-during sinus lift procedures by lateral tween the perforation group comparedwindow preparation. Bone wax, pres- with the intact membrane group. In Devitalization of Adjacent Teethsure, crushing, and electrocautery can contrast, Proussaefs et al41 found im- Adjacent teeth at implant recipientalleviate hemorrhage. In summary, plant survival at second-stage surgery sites should be evaluated before implanthemorrhage treatments at implant os- was superior for the nonperforated placement. Pulpal and periradicularteotomy sites include compression, sites (100%) compared with perfo- conditions such as small periapical ra-finger pressure, vasoconstriction, cau- rated sites (69.6%). Bone density after diolucencies, root resorption and largetery, bone graft, bone cement, and li- grafting should be assessed, regardless restorations in/near the vital pulp aregation of arteries.33 whether or not a perforation occurs, often misdiagnosed. Numerous case because poor bone quality often lead reports33,46,47 describe implant pathosisCortical Plate Perforation to a higher implant failure rate.34 caused by dormant endodontic prob- The buccal cortical plate varies in What happens if an implant pro- lems of adjacent teeth that flare upthickness throughout the mouth and trudes into the maxillary sinus cavity after implant surgery.48 Therefore, it is162 IMPLANT SURGERY COMPLICATIONS
  • 5. worth the time of pulp testing suspi- pausing every 3 to 5 seconds, using should be removed or an attempt tocious teeth and completing a thorough new drills, and an incremental drill place a larger diameter should be com-radiographic examination. If endodon- sequence. Generating less heat by pre- pleted. To leave an unstable implanttic pathosis is identified, root canal paring implant sites at 2500 rpm may without action can often lead to fi-treatment or extraction should be ini- decrease osseous damage.54 brous encapsulation that causes im-tiated before implant placement to pre- Tapping dense cortical bone is plant failure.57 Nonetheless, bone fillvent microbial contamination of the suggested. The benefits of tapping in- will occur in immediate implantsimplant49 during healing and possible clude limiting full osteotomy depth, placed into extraction sockets with afailure. allowing passive implant fit, prevent- marginal defect lateral to the implant Dilacerated roots and excessive ing internal implant-body/implant- wider than 1 mm58 but primary stabil-tilting in the mesiodistal direction that bone interface microfracture, and ity is still a requirement.invade the implant space often prevent compression necrosis, and removingideal placement. If a drill and/or im- drill remnants.53 Mandibular Fractureplant fixture invades the PDL, hard According to Quirynen et al,55 The mandible is the most fre-tooth structure and/or vital pulp, this overpreparation or overheating osteot- quently fractured facial bone,59 manywill lead to endodontic lesions.50 De- omies can result in inactive and active factors have been proposed to contrib-vitalization of an adjacent tooth next retrograde peri-implantitis lesions that ute to the fractures. These include butto an implant delays treatment and can be detected on radiographs as peri- are not limited to site, direction andadds additional financial burden for apical radiolucencies up to a month severity of the force as well as im-both the patient and surgeon. A proper after insertion.47 A good example of an pact.60 Attempts to place implants insurgical guide and a careful radio- inactive lesion is placing a shorter im- patients with severely atrophic mandi-graph analysis are necessary to avoid plant into a larger prepared osteotomy bles increases the risk of fracture, es-improper angulation and hidden dilac- site. Clinically, these lesions are pecially when monocortical grafts anderated roots. asymptomatic and radiographically, ridge-splitting surgeries are com- they present as periapical radiolucen- pleted. In patients who present with cies. As long as the radiolucency stays osteomalacia or osteoporosis, implantPROCEDURE RELATED stable in size and the implant is inte- placement may subject the brittle boneMechanical Complications grated, no treatment is necessary. In to splintering because of the loading or Situations deeming an implant as contrast, problems with microbial in- frictional forces.61 Other reasons for“hopeless” are usually associated with vasion during surgery, such as implant mandibular fracture may include usingsurgical trauma during osteotomy contamination during insertion or the wrong implant (eg, 10 mm sitepreparation with the drill. Ericsson placing the implant into an area with preparation with intent of placing a 12and Albrektsson51 showed bone re- previous inflammation (eg, endodon- or 14 mm implant). Checking the im-sorption occurred at 47°C when dril- tic lesion) can lead to active lesions. A plant size/diameter before opening theling was applied for more than 1 risk of successful treatment can be package is important.minute in rabbits. The result obtained considered in extraction sites with a A fracture of the mandible shouldfrom this study leads to the conclusion history of failed endodontic treatment be restored to maintain form and func-that if temperature or duration in- or adjacent teeth with endodontic tion. Management should includecreases while drilling in bone, necrosis pathology.55 stabilization with an attempt to alsocan occur causing detrimental effects Esposito et al,56 during a review simultaneously eliminate atrophy iffor osseointegration. Nonetheless, of literature to find diagnostic criteria indicated. A retrospective study byErcoli et al52 later reported that the for monitoring implant conditions, Eyrich et al62 found that treatment forharmful temperature only occurred found that surgical trauma and ana- mandibular fractures should be basedwhen drilling was continuous or when tomical conditions both were the most on the type and location of the frac-the drill reached beyond 15 mm during significant etiologic factors for early ture, as well as the severity of the5 osteotomies. implant failures in Branemark im- atrophy. Treatment options included Dense cortical bone (eg, type I plants (3.63%). Interestingly, the ITI using the wiring of a modified pros-bone quality), when compared with implants had higher losses due to peri- thesis, lag screws, wires and plates.type III or IV soft cancellous bone, implantitis and the authors attributed The most relevant option of our fieldcan be overheated when preparing os- design and surface type as the prob- includes combined bone augmentation,teotomies because more pressure is lem. Early implant failures are due to fixation and simultaneous implantneeded to advance the drill apically in excessive surgical trauma along with placement. Increasing mandibularcomparison to soft bone. To reduce impaired wound healing, premature height after augmentation may be un-frictional heat, high speed handpieces, loading and infection.56 predictable but using implants concur-an up-down motion technique of the rently may reduce bone resorption. Ifbone preparation, and copious irriga- Lack of Primary Stability an implant lies in the line of fracture,tion can be used. Misch53 recommends Lack of primary stability is a sur- osseointegration will still occur as longusing external and/or internal irriga- gical complication that should be dealt as there is no mobility or infection.63tion, as well as cool saline irrigation, with at the time of implant surgery. An Another recommended approach forintermittent pressure on the drills, unstable implant (eg, a “spinner”) mandibular fracture is using reduction and IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 163
  • 6. immobilization with monocorticalminiplates to avoid any nonunion and Accumulate datamalunion healing.33 Two miniplates or Medical history, dental history, radiographs, CT, models Assemble treatment plana combination with microplates can Exam, discuss all options, review plan with all disciplinesobtain stable fixation in severely atro- (surgical, restorative, patient and lab)phic fractured mandibles and is a less Approve treatment planinvasive treatment option.64 Signed consent. Patient should understand all risks, benefits, complications and feesIngestion and Aspiration Anticipate problems For the sake of completeness, it Anatomicalshould be mentioned that extreme cau- Nerves (<1mm from implant), vessels, adjacenttion should be emphasized when han- teeth (<.5 mm from implant), type IV bone &dling small implant components in the sinus/nasal floororal cavity. Most instruments have a Mechanicalspecial tip to help ensure screws and Drilling torque, lack of irrigation, incorrectabutments transfer directly from the armamentarium, no surgical guide, implantsurgical tray into the patient’s mouth, contamination, time constraintsbut nevertheless, accidents happen. SystemicUnfortunately, components winding Medications, smoking, DM, head & neck radiation,up on the floor or down a patient’s estrogen therapy, osteoporosisthroat can be embarrassing and expen- Activate treatmentsive mishaps, not to mention serious Achieve anchorageimplications could occur if aspiration No complications, ideal treatment case, primarytakes place. For these reasons, preven- stabilitytative measures such as gauze throat Analyze compromised situationscreens and floss ligatures on implant Dehiscence, fenestration, improperpieces are encouraged. positioning/angulation, Tiwana et al,65 found over a 10 year Accommodate problemretrospective institutional study, only 36 Bone grafting, membranes, sutures, back-upcases of ingestion were reported and implant, shorter implants, root canal therapyamazingly only one case of aspiration. Abort treatmentFixed prosthodontic therapy reported Lack of primary stabilityhaving the most incidences of ingestion. Over-prepped osteotomyIn particular, cemented single-tooth cast Large dehiscence or fenestrationor prefabricated restorations had a Nerve traumahigher likelihood of aspiration. Fracture of the mandible If a patient swallows or aspirates Short distance (<1.5 mm from adjacent tooth)an implant component, they should be Auxillaryreferred to the hospital because acute Refer when indicatedobstruction can be life threatening Accomplish treatmentand prolonging the removal of for- Post operative instructionseign objects may make a bronchos- Post operative medicationscopy technically more difficult.66 If Narcotic, antibiotic, sedative, anti-inflammatorythe foreign object is aspirated itshould be removed within 24 hours. Fig. 6. A guidelines for preventing and managing implant complications.Chest radiographs are a diagnostictool available to rule out ingestion oraspiration. teur implant surgeons hence the data techniques, or lack of communication cannot be generalized. The realization between dental disciplines. TimeOther also exists that many general dentists should be spent in the implant “plan- starting to place implants may have ning” stages, such as tracing preoper- A study done by the Dental Im- more failures and complications com- ative radiographs, measuring models,plant Clinical Research Group67 found pared with experienced specialists. taking CT scans and making properthat inexperienced surgeons ( 50 im-plants) were twice as likely to have surgical guides. Basic anatomy mustimplant failures compared with more CONCLUSION not be forgotten and should be reviewedexperienced surgeons. Such a statistic is Surgical implant complications by the surgeon in every case. As morea good reminder in realizing that some are not uncommon and should be ad- surgically inexperienced dental profes-of our literature is based on the work of dressed immediately. Causality may sionals start placing implants an in-graduate students who start out as ama- be iatrogenic, due to poor treatment crease in surgical complications will164 IMPLANT SURGERY COMPLICATIONS
  • 7. likely occur. In summary, a competent 12. Novaes AB, de Oliveira RR, Taba M 27. Day RH. Microneurosurgery of thesurgeon should be able to treatment Jr, et al. The effects of interimplant dis- injured trigeminal nerve. Oral Maxillofac tances on papilla formation and crestal re- Surg Knowledge Update. 1994;1:91-116.plan a predictable surgery, (Fig. 6) and sorption in implants with a morse cone 28. Goodacre DJ, Rungcharassaengrecognize how to remedy a problem- connection and a platform switch: A histo- K, Kan JY, et al. Clinical complications withatic dental-implant situation. morphometric study in dogs. J Periodon- implants and implant prostheses. J Pros- tol. 2006;77:1839-1849. thet Dent. 2003;90:121-132.Disclosure 13. 2002 Annual Report, National 29. Kalpidis CD, Konstantinidis AB. The authors do not have any fi- Practitioner Data Bank, US DHHS. Critical hemorrhage in the floor of thenancial interests, either directly or in- 14. Givol N, Taicher S, Chaushu G, et mouth during implant placement in the first al. Risk management aspects of implant mandibular premolar position: A case re-directly, in the products listed in the dentistry. Int J Oral Maxillofac Implants. port. Implant Dent. 2005;14:117-124.study. 2002;17:258-262. 30. Longoni. Longoni S, Sartori M, et 15. Parel SM, Funk JJ. The use and al. Lingual vascular canals of the mandible:ACKNOWLEDGMENTS fabrication of a self-retaining surgical guide The risk of bleeding complications during for controlled implant placement; a techni- implant procedures. Implant Dent. 2007;This article was partially supported by cal note. Int J Oral Maxillofac Implants. 16:131-138.the University of Michigan Periodon- 1991;6:207-210. 31. Flanagan D. Important arterial supplytal Graduate Student Research Fund. 16. Blustein R, Jackson R, Godar D, et of the mandible, control of an arterial hemor- al. Use of splint material in the placement of rhage, and report of a hemorrhagic incident.REFERENCES implants. Int J Oral Maxillofac Implants. J Oral Implantol. 2003;29:165-179. 1986;1:47-49. 32. Baab DA, Ammons WF Jr, Selipsky 1. McDermott N, Chuang S, Dodson T, 17. Neidlinger J, Lilien BA, Kalant DC H. Blood loss during periodontal flap sur-et al. Complications of dental implants: Sr. Surgical implant stent: A design modi- gery. J Periodontol. 1977;48:693-698.Identification, frequency, and associated fication and simplified fabrication tech- 33. Park S-H, Wang H-L. Implant re-risk factors. Int J Oral Maxillofac Implants. nique. J Prosthet Dent. 1993;69:70-72. versible complications: Classification and2003;18:848-855. 18. Shotwell JL, Billy EJ, Oh TJ, et al. treatments. Implant Dent. 2005;14:211- 2. Moy PK, Medina D, Aghaloo TL, et Implant surgical guide fabrication for par- 220.al. Dental implant failure rates and associ- tially edentulous patients. J Prosthet Dent. 34. Fugazzotto PA, Wheeler SL, Lind-ated risk factors. Int J Oral Maxillofac Im- 2005;93:294-297. say JA. Success and failure rates of cylin-plants. 2005;20:569-577. 19. Heller AA, Shankland WE II. Alter- der implants in type IV bone. J Periodontol. 3. Choi M, Romberg E, Driscoll CF. Ef- native to the inferior alveolar nerve block 1993;64:1085-1087.fects of varied dimensions of surgical anesthesia when placing mandibular den- 35. Katranji A, Misch K, Wang H-L.guides on implant angulations. J Prosthet tal implants posterior to the mental fora- Cortical bone thickness in dentate andDent. 2004;92:463-469. men J Oral Implantol. 2001;27:127-133. edentulous human cadavers. J Periodon- 4. Wong N, Huffer-Charchut H, Sarment 20. Worthington P. Injury to the inferior tol. 2007;78:874-878.D. Computer-aided design/computer-aided alveolar nerve during implant placement: A 36. Tinti C, Parma-Benfenati SP. Clini-manufacturing surgical guidance for place- formula for protection of the patient and cal classification of bone defects concern-ment of dental implants: Case report. Implant clinician. Int J Oral Maxillofac Implants. ing the placement of dental implants. Int JDent. 2007;16:123-130. 2004;19:731-734. Periodontics Restorative Dent. 2003;23: 5. Jabero M, Sarment DP. Advanced 21. Bartling R, Freeman K, Kraut RA. 147-155.surgical guidance technology: A review. The incidence of altered sensation of the 37. Shin HI, Sohn DS. A method ofImplant Dent. 2006:15;135-142. mental nerve after mandibular implant sealing perforated sinus membrane and 6. Williams PL, Warwick R. Gray’s placement. J Oral Maxillofac Surg. 1999; histologic finding of bone substitutes: AAnatomy. 36th ed. Edinburgh: Churchill 57:1408-1410. case report. Implant Dent. 2005;14:328-Livingstone; 1980:1281-1287. 22. Van Steenberghe D, Lekholm U, 335. 7. Tanaka T, Shaw P. Anatomy for im- Bolender C, et al. Applicability of os- 38. Kim S-G, Mitsugi M, Kim B-O. Si-plant dentistry: Mandible. Quintessence seointegrated oral implants in the rehabili- multaneous sinus lifting and alveolar dis-Dent Implantol. 1995;2:10-20. tation of partial edentulism: A prospective traction of the atrophic maxillary alveolus 8. Choquet V, Hermans M, Malevez C, multicenter study on 558 fixtures. Int J Oral for implant placement: A preliminary re-et al. Clinical and radiographic evaluation Maxillofac Implants. 1990;5:272-281. port. Implant Dent. 2005;14:344-348.of the papilla level adjacent to single-tooth 23. Ellies L, Hawker P. The prevalence 39. Tatum H. Maxillary and sinus im-dental implants. A retrospective study in of altered sensation associated with im- plant reconstructions. Dent Clin North Am.the maxillary anterior region. J Periodontol. plant surgery. Int J Oral Maxillofac Im- 1986;30:207-229.2001;72:1364-1371. plants. 1993;8:674-679. 40. Ardekian L, Oved-Peleg E, Peled 9. Tarnow DP, Cho SC, Wallace SS. 24. Nazarian Y, Eliav E, Nahlieli O. [He- M, et al. The clinical significance of sinusThe effect of inter-implant distance on the brew] Nerve injury following implant membrane perforation during augmenta-height of inter-implant bone. J Periodontol. placement: Prevention, diagnosis and tion of the maxillary sinus. J Oral Maxillofac2000;71:546-549. treatment modalities. Refuat Hapeh Ve- Surg. 2006;64:277-282. 10. Tarnow DP, Magner AW, Fletcher P. hashinayim. 2003;20:44-50. 41. Proussaefs P, Lozada J, RohrerThe effect of the distance from the contact 25. Kraut RA, Chahal O. Management MD, et al. Repair of the perforated sinuspoint to the crest of bone on the presence or of patients with trigeminal nerve injuries af- membrane with a resorbable collagenabsence of the interproximal dental papilla. J ter mandibular implant placement. JADA. membrane: A human study. Int J Oral Max-Periodontol. 1992;63:995-996. 2002;133:1351-1354. illofac Impl. 2004;19:413-420. 11. de Oliveira RR, Novaes A Jr, Taba 26. Hegedus F, Diecidue RJ. Trigemi- 42. Jung JH, Choi BH, Li J, et al. TheM Jr, et al. Influence of interimplant dis- nal nerve injuries after mandibular implant effects of exposing dental implants to thetance on papilla formation and bone placement-Practical knowledge for clini- maxillary sinus cavity on sinus complica-resorption: A clinical-radiographic study in cians. Int J Oral Maxillofac Implants. 2006; tions. Oral Surg Oral Med Oral Pathol Oraldogs. J Oral Implantol. 2006;32:218-227. 21:111-116. Radiol Endod. 2006;102:602-605. IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 165
  • 8. 43. Peleg M, Garg AK, Mazor Z. Pre- study in the rabbit. J Prosthet Dent. 1983; R, Schneider E, et al. Significance of osteo-dictability of simultaneous implant place- 50:101-107. porosis in craniomaxillofacial surgery: A re-ment in the severely atrophic posterior 52. Ercoli C, Funkenbusch PD, Lee HJ, view of the literature. Osteoporos Int.maxilla: A 9-year longitudinal experience et al. The influence of drill wear on cutting 2006;17:167-179.study of 2,132 implants placed into 731 efficiency and heat production during os- 62. Eyrich GKH, Gratz KW, Sailer HF.human sinus grafts. Int J Oral Maxillofac teotomy preparation for dental implants: A Surgical treatment of fractures of the eden-Implants. 2006;21:94-102. study of drill durability. Int J Oral Maxillofac tulous mandible. J Oral Maxillofac Surg. 44. Nakamura N, Mitsuyasu T, Ohishi Implants. 2004;19:335-349. 1997;55:1081-1087.M. Endoscopic removal of a implant dis- 53. Misch CE. Contemporary Implant 63. Tolman DE, Keller EE. Manage-placed in the maxillary sinus; a technical Dentistry. 2nd ed. St. Louis, MO: Mosby; ment of mandibular fractures in patientsnote. Int J Oral Maxillofac Surg. 2004;33: 1999:373. with endosseous implants. Int J Oral Max-195-197. 54. Sharawy M, Misch CE, Tehemar S, illofac Implants. 1991;6:427-436. 45. Varol A, Turker N, Basa S, et al. et al. Heat generation during implant 64. Mugino H, Takagi S, Ikemura K, etEndoscopic retrieval of dental implants drilling: The significance of motor speed. al. Miniplate osteosynthesis of fractures offrom the maxillary sinus. Int J Oral Maxillo- J Oral Maxillofac Surg. 2002;60:1160- the edentulous mandible. Clin Oral Inves-fac Implants. 2006;21:801-804. 1169. tig. 2005;9:266-270. 46. Oh T-J, Joongkyo Y, Wang H-L. 55. Quirynen M, Gijbels F, Jacobs R. 65. Tiwana K, Morton, Tiwana PS. As-Management of the implant periapical An infected jawbone site compromising piration and ingestion in dental practice: A successful osseointegration. Periodontol 10-year institutional review. JADA. 2004;lesions: A case report. Implant Dent. 2003; 2000. 2003;33:129-144. 135:1287-1291.12:41-46. 56. Esposito M, Hirsch JM, Thomsen 66. Zitman NU, Marinello CP. The as- 47. Ayangco L, Sheridan PJ. Develop- P, et al. Biological factors contributing to piration and swallowing of foreign bodies.ment and treatment of retrograde peri- failures of osseointegrated oral implants. The management of the aspiration or swal-implantitis involving a site with a history of (I). Success criteria and epidemiology. Eur lowing of foreign bodies during dentalfailed endodontic and apicoectomy J Oral Sci. 1998;106:527-551. treatment. Schweiz Mon atsschr Zah-procedures: A series of reports. Int J Oral 57. Lioubavina-Hack N, Lang NP, nmed. 2000;110:619-632.Maxillofac Implants. 2001;16:412-417. Karring T. Significance of primary stability 67. Truhlar RS, Morris HF, Ochi S, et al. 48. Shaffer MD, Juruaz DA, Haggerty for osseointegration of dental implants. Second stage failures related to bone qual-PC. The effect of periradicular endodontic Clin Oral Impl Res. 2006;17:244-250. ity in patients receiving endosseous dentalpathosis on the apical region of adjacent 58. Botticelli D, Berglundh T, Lindhe J, implants DICRG, Interim report #7. Implantimplants. Oral Surg Oral Med Oral Pathol et al. The jumping distance revisited: An Dent. 1994;3:252-255.Oral Radiol Endod. 1998;86:578-581. experimental study in the dog. Clin Oral 49. el Askary AS, Meffert RM, Griffin T. Implants Res. 2003;14:35-42. Reprint requests and correspondence to:Why do dental implants fail? Part I. Implant 59. Olson RA, Fonseca RJ, Osbon DB, Hom-Lay Wang, DDS, MSD, PhDDent. 1999;8:173-185. et al. Fractures of the mandible: A review of Department of Periodontics and Oral Medicine 50. Sussman HI. Tooth devitalization 580 cases. J Oral Maxillofac Surg. 1982; University of Michigan, School of Dentistryvia implant placement: A case report. Peri- 40:23-28. 1101 N. Universityodontal Clin Investig. 1998;20:22-24. 60. Reitzik M, Lownie JF, Austin J, et Ann Arbor, MI 48109-1078 51. Ericksson RA, Albrektsson T. Tem- al. Experimental fractures of monkey man- Phone: 734-763-3383perature threshold levels for heat-induced dibles. Int J Oral Surg. 1978;7:100-103. Fax: 734-936-0374bone tissue injury: A vital-microscopic 61. Hohlweg-Majert B, Schmelzeisen E-mail: homlay@umich.edu Abstract Translations glichst erfolgreiche Problembewaltigung Bescheid zu wissen. ¨ GERMAN / DEUTSCH Die vorliegende Studie zielt darauf ab, die Herausforderun-AUTOR(EN): Kelly Misch, DDS, Hom-Lay Wang, DDS, gen hinsichtlich der Behandlung von Komplikationen inMSD, PhD. Korrespondenz an: Hom-Lay Wang., DDS., MSD, Verbindung mit dem Behandlungsplan, der spezifischenPhD, Abteilung fur Parodontie und Oralmedizin (Dept. of Pe- ¨ Patientenanatomie und dem Behandlungsvorgehen heraus-riodontics and Oral Medicine), Universitat von Michigan (Uni- ¨ ´ zustellen sowie die Atiologie und die Optionen fur Problem- ¨versity of Michigan), zahnmedizinische Fakultat (School of ¨ bewaltigung und Behandlung mit dem Ziel eines zufrieden ¨Dentistry), 1101 N. University, Ann Arbor, MI 48109-1078. stellenden Behandlungsergebnisses zu diskutieren.Telefon: 734-763-3383, Fax: 734-936-0374, eMail: homlay@ ¨ ¨ SCHLUSSELWORTER: Zahnimplantate; Implantierungs-umich.edu komplikationen; Versagen von Zahnimplantaten. ´Komplikationen bei Implantationsoperationen: Atiologie &BehandlungZUSAMMENFASSUNG: In der Zahnheilkundlichen Praxis SPANISH / ESPAÑOLtreten haufig Komplikationen bei Implantierungsoperationen ¨ AUTOR(ES): Kelly Misch, DDS, Hom-Lay Wang, DDS,auf. Es ist von maßgeblicher Bedeutung, hier uber eine mo- ¨ ¨ MSD, PhD. Correspondencia a: Hom-Lay Wang., DDS.,166 IMPLANT SURGERY COMPLICATIONS
  • 9. MSD, PhD, Dept. of Periodontics and Oral Medicine, Uni- versity of Michigan, School of Dentistry, 1101 N. University,versity of Michigan, School of Dentistry, 1101 N. University, Ann Arbor, MI 48109-1078. л фо : 734-763-3383.,Ann Arbor, MI 48109-1078. Telefono: 734-763-3383, Fax: 734- ´ Ф кс: 734-936-0374, д с л к о о о :936-0374, Correo electronico: homlay@umich.edu ´ homlay@umich.eduComplicaciones de la cirugıa de implante: Etiologıa y tratamiento ´ ´ Осло , с с у г ско л : олог лABSTRACTO: Las complicaciones de la cirugıa de implante ´son ocurrencias frecuentes en la practica odontologica y el ´ ´ . Осло у г ско л -conocimiento de la atencion de estos casos es esencial. El ´ л с с лobjetivo de este trabajo es destacar los desafıos en el trata- ´ с о олог ско к к , о о у о оmiento de complicaciones quirurgicas relacionadas con el ´ од бо б с к слу . л огоplan, con la anatomıa y los procedimientos ası como explicar ´ ´ об о — ок уд ос л у г скla etiologıa, atencion y opciones de tratamiento para lograr un ´ ´ осло ,с с л о л , оresultado satisfactorio. о ду о , к обсуд олог , од бо б л дл досPALABRAS CLAVES: Implantes dentales; complicaciones удо л о л ого ул .del implante; falla del implante. КЛ СЛО : уб л ; осло л ; уд л - PORTUGUESE / PORTUGUÊS .AUTOR(ES): Kelly Misch Cirurgiao-Dentista, Hom-Lay ˜Wang Cirurgiao-Dentista, Mestre em Odontologia, PhD. ˜ ¨ TURKISH / TURKCE ¸Correspondencia para: Hom-Lay Wang., DDS., MSD, PhD, ˆ YAZARLAR: Diçs Hekimi Kelly Misch, Diçs Hekimi Hom-Dept. of Periodontics and Oral Medicine, University of Mich- Lay Wang. Yazısma icin: Hom-Lay Wang., DDS., MSD, PhD, ¸ ¸igan, School of Dentistry, 1101 N. University, Ann Arbor, MI Dept. of Periodontics and Oral Medicine, University of Mich-48109-1078. Telefone: 734-763-3383, Fax: 734-936-0374, igan, School of Dentistry, 1101 N. University, Ann Arbor, MIe-mail: homlay@umich.edu 48109-1078 ABD. Telefon: 734-763-3383, Faks: 734-936-Complicacoes de Cirurgia de Implante: Etiologia & ¸˜ 0374, eposta: homlay@umich.eduTratamento Oral mplantolojide Profilaksi Amacıyla Antibiyotik Re-RESUMO: Complicacoes de cirurgia de implante sao ocor- ¸˜ ˜ jimi: Nedenler ve Protokolrencias frequentes na pratica dentaria e o conhecimento da ˆ ¨ ´ ´ ÖZET: Oral implantolojide antimikrobiyal ilaç kullanımı,gestao desses casos e essencial. O objetivo desta revisao e ˜ ´ ˜ ´ cerrahi yaradaki enfeksiyonları azaltır. Antimikrobiyal pro-realcar os desafios de complicacoes cirurgicas relacionadas a ¸ ¸˜ ´ filaksi, tüm Sınıf 2 (temiz-kontamine) cerrahi prosedürleriplanos de tratamento e a anatomia, bem como discutir as için endike olup, bunlara dental implantın bakteriyel kon-opcoes de etiologia, gestao e tratamento para alcancar um ¸˜ ˜ ¸ taminasyonu sırasında yeterli düzeyde kan bulunan cerrahiresultado de tratamento satisfatorio. ´ prosedürler ile kemik greft prosedürleri de dahildir. Antibiyo-PALAVRAS-CHAVE: Implantes dentarios; complicacoes de ´ ¸˜ tiklerin etkinlii açısından zamanlama ve doz, kritik önemimplantes; falhas de implantes. taçır. Antibiyotik genelde prosedür nedeniyle enfeksiyona sebep vermesi en olası olan bakteriye göre seçilir. Yazarlar, diç hekiminin uygun çekilde ilaç reçetelemesine yardımcı RUSSIAN / olmak üzere prosedüre, yerel konakçıya ve sistemik faktörlere О : Kelly Misch, док о с о олог , Hom- dayanan bir sınıflama ve protokol sistemi geliçtirmiçlerdir.Lay Wang, док о с о олог , г с у г ско с о олог , , док о ф лософ . ANAHTAR KELMELER: dental implantlar, antibiyotik д с дл ко с о д : Hom-Lay Wang., DDS., profilaksi, cerrahi yara enfeksiyonu, farmakolojik protokol,MSD, PhD, Dept. of Periodontics and Oral Medicine, Uni- risk faktörleri. IMPLANT DENTISTRY / VOLUME 17, NUMBER 2 2008 167
  • 10. JAPANESE / CHINESE / KOREAN / PhD PhD168 IMPLANT SURGERY COMPLICATIONS