Dental implant complications


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implants, complications, failures, periimplantitis, management of implant complications

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  • @Oral Implantology Research Institute : thank you so much. will surely ask for clinical photos when im improving my seminar again. kind of you to offer!
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  • Great presentation, I teach complication seminars in 3 days and still I found yours very easy to grasp and to learn from. Keep it up. I have more than 100 thousand photos of my own implant cases with many complications If you need a photo on a specific complication I will send it to you and you can make your presentations with more clinical photos if you like.
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  • should differentiate between two concepts: accidents and complications (Annibali et al,
  • as in the case of implantology procedures, without the interruption of medication and as long as values concerning
  • are factors that trigger the occurrence of edemas and patient’s susceptibility.
  • using non-excessive tension and bone-supported retriever

    Use of a, and

    Before the suspicion that the inflammation could compress any nervous structure, are crucial to minimize the risk of lesions (Misch & Resnik, 2010).
  • A flow diagram of airway management and control of massive hemorrhage in the
    floor of mouth associated with implant placement in the anterior mandibular region
    (Kalpidis & Setayesh, 2004).
  • Mylohyoid artery branch of ia artery as it enters the mandibular foramen
  • inhibit axon sprouting centrally and ectopic discharges from injured axons-
  • (Park & Wang, 2005) and formation of sequestration of bone debris
  • because the granulation tissue that forms will promote healing by secondary intention. Use of ct grafts guaranteeing the
    closure of the wound and the enlargement of the mucosa thickness around implants,
  • sharper angles observed at the inner walls of the sinus
    in the vicinity of the second upper bicuspid presents a higher risk of perforation

  • when bone volume is inadequate to support an implant with sufficient length,
  • orthopedic revisions,
    craniofacial defects, or post oral cancer ablation associated with surgery/radiation.
  • by correcting crown-root proportion, contour of soft tissues and the relation with neighboring teeth. (based on the osteogenic distraction of a bone fragment containing the integrated implant)

  • that can increase the availiable bone length by 50
  • worth mentioning a case report describing the migration of a zygomatic implant
    to the cranial fossa. This is a major complication that can end up with a cerebral lesion or an
    infection that must be prevented with a preoperative and postoperative three-dimensional
    radiographic study (Reychler & Olszewski, 2010).
  • 1.5 to 2 mm of bone should be present between an implant and the adjacent tooth. Malpositioned implant- adjacent teeth non vital- endodontic procedure
  • provide enough blood for the healing process derived from an implant placement
    (Chrcanovic & Custodio, 2009). The bone in this area is usually sclerotic and undergoes
    severe resorption as a consequence of a large period of edentulism
  • More than 80% of factures are located in the molar and premolar regions. specially cantilevers in fixed prostheses, occlusal overload or/ and parafunctional habits
  • Dental implant complications

    2. 2. Introduction • Implantology is an ever growing field. • Nevertheless, it has, as every surgical procedure, several complications that can occur and that must be known in order to prevent or solve them. • It is mandatory to classify all those clinical complications that can arise.
    3. 3. • Accidents are events that occur during surgery Accidents always happen during surgical procedures. • Complications appear lately, once surgery is already performed. There are two kinds of complications, depending on the time they emerge: early and late. Early-stage complications appear in the immediate postoperative period and interfere with healing, Late-stage complications arise during the process of osseointegration.
    4. 4. • Failures occur when the professional and/or the patient do not obtain the desirable results • Iatrogenic acts are regarded as accidents, complications or failures caused by a deficient praxis of the professional (Annibali et al, 2009)
    5. 5. Local complications in dental implant surgery. • Infection • Edema • Ecchymoses and haematomas • Emphysema • Bleeding • Flap dehiscence • Sensory disorders
    6. 6. • Perforation of the mucoperiosteum • Maxillary sinusitis • Mandibular fractures • Failed osseointegration • Bony defects • Periapical implant lesion (Misch and Wang,2008)
    7. 7. CLASSIFICATION (Carranza) • Surgical complications • Biologic complications • Technical or mechanical complications • Esthetic and phonetic complications
    8. 8. Surgical complications • Hemorrhage and hematoma • Neurosensory disturbances • Damage to adjacent teeth Biologic complications • Inflammation • Dehiscence and recession • Periimplantitis and bone loss • Implant loss or failure
    9. 9. Technical complications • Screw loosening and fracture • Implant fracture • Fracture of restorative materials Esthetic and phonetic complications • Esthetic complications • Phonetic complications
    10. 10. Bleeding • Common accident as a consequence of local-anatomical or systemic causes. Causes of bleeding: lesions in any sublingual, lingual, perimandibular, or submaxillary artery Surgeries in the lower and anterior area of totally edentulous patients who have a deficit in the quality and quantity of bone.
    11. 11. • More prone patients fall in the following category: Group 2 of medical-systemic risk:  Irradiated patients (radiotherapy),  Patients with coagulation disorders (anticoagulated patients or those with haemostatic disorders)  Severe smokers (Buser et al., 2000)
    12. 12. • Group I includes high risk patients:  Patients with serious systemic diseases (rheumatoid arthritis, osteomalacia, imperfect osteogenesis),  Immunodepressed (HIV, immunosupresory treatments),  Drug addicts (alcohol, etc.),  Unreliable patients (mental or psychological disorders).
    13. 13. • Elderly - probability of comorbidity is higher and mandatory to know their medical history. Therapeutic options in these patients comprise two approaches: Decrease or eliminate the anticoagulant therapy once patient and physician have assessed risks and benefits. Invasive treatments can be performed ( Bacci et al., 2010): International Normalized Ratio (INR) are > 4, and Adequate hemostatic measures are followed and, Use atraumatic surgery techniques;
    14. 14. Treatment: local intraoperative or postoperative measures Local hemostasis (suture, compression, the use of hemostatic microfibrilar collagen gauzes, oxidized cellulose, reabsorbable fibrin, or mouth rinsing with 4,8% of tranexamic acid) Precautions to be taken: Strongly recommended to carry out an exhaustive tomography study of the anatomy of mandible and maxilla.
    15. 15. • Swelling - more noticeable 24 hours after performing surgery • Causes: Wide flaps, Bone regenerating techniques, and surgery time Edema
    16. 16. • Leads to trismus, lack of hygiene in the wound and discomfort to the patient. • Decreases with time, and can easily vanish after a few days.
    17. 17. Management Careful management of tissues Non-steroid anti- inflammatory drugs cold pack corticosteroids
    18. 18. Hemorrhage/ Ecchymosis • Severe bleeding and the formation of massive hematomas in the floor of the mouth are the result of an arterial trauma. Several types of hemorrhagic patches can develop as a result of injury: Petechiae (<2 mm in diameter), Purpura (2 to 10 mm), and Ecchymosis (>10 mm).
    19. 19. Ecchymosis are the result of an intermental surgery procedure.
    20. 20. A schematic representation of the arterial anatomy in the floor of the mouth (Kalpidis & Setayesh, 2004).
    21. 21.  Swelling and elevation of floor of the mouth  Increase in tongue size  Difficulty in swallowing or speech  Pulsating or profuse bleeding from the floor of the mouth or the osteotomy site
    22. 22. Bleeding site during implant osteotomy Arteries Treatments Posterior mandible Mylohyoid Finger pressure at the site Middle lingual of mandible Submental Surgical ligation of facial and lingual arteries Anterior lingual of mandible Terminal branch of sublingual or submental Compression, vasoconstriction, cauterization, or ligation Invading the mandibular canal Inferior alveolar artery Bone graft Treatment of a hemorrhage at an implant osteotomy site (Park & Wang, 2005)
    23. 23. • The blood supply of the maxillary sinus is derived from the infraorbital artery, the greater palatine artery and the posterior superior alveolar artery (Chanavaz, 1990; Uchida et al., 1998a). • Bleeding during sinus augmentation is rare because the main arteries are not within the surgical area.
    24. 24. Emphysema • Rare complication, though it can lead to severe consequences (McKenzie & Rosenberg, 2009). • Causes Inadvertent insufflation propulsion of air into tissues under skin or mucous membranes, Air from a high-speed handpiece, air/water syringe, an air polishing unit or an air abrasive device can be projected into a sulcus, surgical wound, or a laceration in the mouth (Liebenberg & Crawford, 1997)
    25. 25. Neurosensory disturbances • Nerve lesions are both an intraoperative accident and a postoperative complication that can affect the infra-orbital nerve, the inferior alveolar nerve, or its mental branch and the lingual nerve. • These complications have a low incidence (reported between 0%-44%) (Misch & Resnik, 2010)
    26. 26. Several implants in contact to the Inferior Alveolar nerve in patients with postoperative paresthesia.
    27. 27. Causes • INDIRECT Postsurgical intra-alveolar edema or hematomas- produce a temporary pressure increase, especially inside the mandibular canal • DIRECT Compression, stretch, cut, overheating, and accidental puncture (Annibali et al., 2009)
    28. 28. • Poor flap design, • Traumatic flap reflection, • Accidental intraneural injection, • Traction on the mental nerve in an elevated flap, • Penetration of the osteotomy preparation • Compression of the implant body into the canal (Misch & Wang, 2008).
    29. 29. The nerve injury may cause one of the following conditions: • Parasthesia (numb feeling), • Hypoesthesia (reduced feeling), hyperesthesia (increased sensitivity), • Dysthesia (painful sensation), or • Anesthesia (complete loss of feeling) of the teeth, the lower lip, or the surrounding skin and mucosa (Greenstein & Tarnow, 2006 as cited in Sharawy & Misch, 1999).
    30. 30. • Neurapraxia: there is no loss of continuity of the nerve; it has been stretched or undergone blunt trauma; the parasthesia will subside, and feeling will return in days to weeks. • Axonotmesis: nerve damaged but not severed; feeling returns within 2 to 6 months. • Neurotmesis: severed nerve; poor prognosis for resolution of parasthesia.
    31. 31. Sharp needle test( tingle or painful) Shortest test between indentation Blunt cotton swab test( tingle or painfulor none) Pulp testing teeth Mapping area of altered feeling Temperatures test( cold, warmth)optional
    32. 32. Recommendations to avoid nerve injuries during implant placement (Worthington,2004) Be sure to include nerve injury as an item in the informed consent document. Measure the radiograph with care. Apply the correct magnification factor. Consider the bony crestal anatomy: Is the buccolingual position of the crestal peak of bone influencing the measurement of available bone? Consider the buccolingual position of the nerve canal. Use coronal true-size tomograms where needed. Allow a 1 to 2 mm safety zone. Use a drill guard. Take care with countersinking not to lose support of the crestal cortical bone. Keep the radiograph and the calculation in the patient’s chart as powerful evidence of meticulous patient care.
    33. 33. Treatment (Misch & Resnik, 2010). • Too much proximity between the implant and a nerve- removal as soon as possible • Treatment with corticosteroids and non-steroidal anti- inflammatory drugs - to control inflammatory reactions that provoke nervous compression. • Topical application of dexamethasone (4 mg/ml) for 1 or 2 minutes enhances recovery, • Oral administration (high doses)- within one week of injury- prevention of neuroma formation
    34. 34. • Remove offending element • Corticosteroids • Recovery on 1 to 4 weeks NEUROPRAXIA • Remove offending element • Corticosteroids • Recovery on 1 to 3 months AXONOTMESIS • Complete anesthesia for more than 3 months • May have triggering signs or increase in sensation to sharp stimuli NEUROTMESIS
    35. 35. • Intraoperative nerve section - microsurgery techniques to reestablish nerve continuity. • Neurosensorial loss - checked at different moments to determine with precision the evolution of the lesion • Resort to microsurgery if, after four months - patient’s situation has not improved, pain persists and there is a remarkable loss of sensitivity.
    36. 36. Aspiration and swallowing of instruments Images of a screw driver in the digestive tract. (b) Screw driver into pulmonary tissue.
    37. 37. • Vital emergency if the instrument has entered the airways. • Recommended to tie all tiny and slippery instruments with silk ligatures or else use a rubber dam (Bergermann et al., 1992). • Gastroscopy or colonoscopy with a proper medical follow-up required to locate.
    38. 38. Flap dehiscence and exposure of graft material or barrier membrane • The most common postoperative complication is wound dehiscence, which sometimes occurs during the first 10 days (Greenstein et al., 2008). Wound dehiscence at one week post surgery in a diabetic patient with oral candidiasis
    39. 39. • Flap tension, • Continuous mechanical trauma or irritation associated with the loosening of the cover screw, • Incorrect incisions • Poor-quality mucosa (thin biotype, traumatized), • Heavy smokers, patients treated with corticosteroids, diabetics, or irradiated patients (Lee & Thiele, 2010)
    40. 40. (Speroni et al., 2010; Stimmelmayr et al., 2010). •No surgical correctionSmall dehiscence- • ResuturingLarge dehiscence Free connective tissue grafts - - allows better esthetical results , maintenance of periimplant health
    41. 41. 1) Careful preoperative assessment of the soft tissues to measure the amount of keratinized mucosa present and planning of augmentation procedures as appropriate; 2) Minimally invasive flap elevation and reflection with careful removal of any bone débris beneath; 3) Proper suturing; 4) Sensible temporization, rebasing and relining; and 5) Delaying the use of removable dentures until two weeks after surgery.
    42. 42. Complications associated with maxillary sinus lift • The Schneiderian membrane- characterized by periosteum overlaid with a thin layer of pseudociliated stratified respiratory epithelium, • Constitutes an important barrier for the protection and defense of the sinus cavity.
    43. 43. Schneiderian membrane perforation occurs in 10% to 60% of all procedures
    44. 44. Anatomical variations such as a maxillary sinus septum, spine, or sharp edge are present Very thin or thick maxillary sinus walls Angulation between the medial and lateral walls of the maxillary sinus seemed to exert an especially large influence on the incidence of membrane perforation.
    45. 45. • folding the membrane up against itself as the membrane is elevated Small tears (<5 to 8 mm) • do not lend themselves to closure by infolding • Repaired with collagen or a fibrin adhesive Larger tears
    46. 46. Loss of the implant or graft materials into the maxillary sinus Changes in intrasinal and nasal pressures; Autoimmune reaction to the implant, causing peri-implant bone destruction and compromising osseointegration; and Resorption produced by an incorrect distribution of occlusal forces (Galindo et al., 2005)
    47. 47. Immediately retrieved surgically via an intraoral approach or endoscopically via the transnasal route to avoid inflammatory complications a bone reconstruction procedure of the maxilla should be performed.
    48. 48. Malposition or angulation of an implant • The definition of a ‘malpositioned implant’ is an implant placed in a position that created restorative and biomechanical challenges for an optimal result. most common - deficiency of the osseous housing around the proposed implant site. Bone resorption : osseous remodeling following tooth loss, osteoporosis, etc.
    49. 49. Use of repositioning system. Improves esthetic effects, the biomechanical behavior of the implant
    50. 50. : • Assess the characteristics of the edentulous zone subject to rehabilitation using clinical and radiological CT, or cone beam CT imaging (Dreiseidler et al., 2009) • Use short or tilted implants (aproximately 30º) or” • avoid anatomical structures (mental nerve, maxillary sinus).
    51. 51. Improper implant location/Implant displacement (a) Implant installed . (b) Control CT Scan after displacement and before second stage surgery. (c) Change of position.
    52. 52. There is an absence or loss of osseointegration and, Loss of stability If in the sinus: can be removed a few days later by opening the lateral wall of the maxillary sinus, or by endoscopic via through a nasal window. Accurate surgical technique - using osteotomes to prepare the implant beds or a drill with a smaller diameter to that of the fixture, or using implants with a conical compressive form.
    53. 53. Injury to adjacent teeth • This problem arises more frequently with single implants A malpositioned implant hitting an adjacent tooth
    54. 54. • Damage to teeth adjacent to the implant site- subsequent to the insertion of implants along an improper axis or after placement of excessively large implants. • Risk of a retrograde Periimplantitis- distance between tooth and implant apexes is shorter and when the lapse of time between the endodontic procedure and the implantation is also shorter (Quirynen et al., 2005; Tozum et al., 2006; Zhou et al., 2009).
    55. 55. • Use of a surgical guide, radiographic analysis and CT scan can help locate the implant placement. • Inspection of a radiograph with a guide pin at a depth of 5 mm will facilitate osteotomy angulation corrections (Greenstein et al., 2008). • Prevent a latent infection of the implant from the potential endodontic lesion, endodontic treatment should be performed
    56. 56. Mandibular fracture Perforation of the lingual cortical during drilling. Infrequent complication
    57. 57. • Associated with atrophic mandibles • Central area of the mandible has a greater risk for this complication Reduction and stabilization of the fracture with titanium miniplates or resorbable miniplates. Splinting implants to reduce and immobilize the fracture Thin mandibular alveolar crests- increase width by performing bone grafts Accurate tomography imaging study
    58. 58. Screw loosening • Incidence- 6% • Causes: Stress applied to prosthesis Crown height Cantilever Height or depth of antirotational component Platform dimensions on which the abutment is seated
    59. 59. • Large diameter implants with large platform dimensions reduce the forces applied to the screw • Decreased preload force • Increase thread tightening
    60. 60. IMPLANT EXPOSURE • Can be associated with exudate and bone loss : Complete exposure of the implant cover screw Removal of the healing cover Flushing of the implant with chlorhexidine, insertion of a permucosal extension Oral hygiene with soft toothbrush Chlorhexidine application over the area twice each day
    61. 61.  PME inserted, tissue approximated  Membrane can be used  Antibiotics and chlorhexidine daily rinses  Uncovering of implant, removal of cover screw  Curetting of granulation tissue  Cleaning of implant surface-diamond bur/ air abrasive  Bone grafts and membrane
    62. 62. Implant fracture • Infrequent complication (among 0,2 y- 1.5% of cases ) (Eckert et al., 2000) • Complications is higher in implants supporting fixed partial prosthesis than in complete edentulous patients. • Causes: Defects in the implant design or materials used in their construction, A non-passive union between the implant and the prosthesis or by mechanical overload,
    63. 63. Management: Removal of the implant and its replacement by another one (a) Implant fractured in maxillary posterior region. (b) Implants retrieved. (c) Substitution for a wider diameter in the same surgery
    65. 65. Periimplantitis • Peri-implantitis is defined as an inflammatory process which affects the tissues around an osseointegrated implant in function, resulting in the loss of the supporting bone, which is often associated with bleeding, suppuration, increased probing depth, mobility and radiographical bone loss.
    66. 66. • Peri-implant mucositis was defined as reversible inflammatory changes of the peri- implant soft tissues without any bone loss (Albrektsson & Isidor 1994) In a systematic analysis, 2003 • Incidence of periimplmant mucositis- 8-44% • Incidence of periimplantitis- 1- 19%
    67. 67. Periimplant mucositis
    68. 68. Periimplantitis
    69. 69. • History of periodontitis • Smoking • Poor oral hygiene • Exposed threads • Exposed surface coatings (roughened surfaces) • Deep pockets (placed too deep, placed into deficiencies) • No plaque removal access (ridge lap crown, connected prostheses) Risk factors for peri- implantitis
    70. 70. Features Radiological evidence for vertical destruction of the crestal bone Saucer shaped defect Bleeding and suppuration on probing Pain Formation of a peri-implant pocket Swelling of the peri-implant tissues and hyperplasia
    71. 71. Diagnosis • Clinical indices, • peri-implant probing, • bleeding on probing (BOP), • suppuration, • mobility, • peri-implant radiography • microbiology.
    72. 72. DIAGNOSTIC DIFFERENCES BETWEEN PERIIMPLANTITIS AND PERIIMPLANT MUCOSITIS Clinical parameter Peri-implant mucositis Peri-implantitis Increased probing depth +/- + BOP + + Suppuration +/- + Mobility - +/- Radiographic bone loss - +
    73. 73. Treatment of peri-implant infection (adapted from Mombelli & Lang 2004) Peri-implant pockets 3mm No visible plaque, No BOP No therapy needed Plaque, BOP OHI and local debridement
    74. 74. Peri-implant pockets >3mm No loss of bone when compared to baseline, No BOP, no visible plaque Plaque+/_ BOP No therapy needed OHI and local debridement Surgical resection
    75. 75. Loss of bone when compared to baseline mild moderate OHI and local debridement Topical antiseptic treatment Local/ systemic antibiotic delivery Open debridement severe OHI and local debridement Local/systemic antibiotic delivery Open debridement Explantation OHI and local debridement Surgical resection Topical antiseptic treatment Local antibiotic delivery Systemic antibiotic delivery
    76. 76. • A. using rubber cups and polishing paster, acrylic scalers for chipping off calculus. Effective oral hygiene practices. • B. Rinses with 0.1% to 0.2% chlorhexidine digluconate for 3 to 4 weeks, • supplemented by irrigating locally with chlorhexidine (preferably 0.2% to 0.5%) Cumulative Interceptive Supportive Therapy (CIST) modalities (Lang et al, 2004).
    77. 77. : 1. SYSTEMIC ornidazole (2 x 500 mg/day) or metronidazole (3 x 250 mg/day) for 10 days OR combination of metronidazole (500 mg/day) plus amoxicillin (375 mg/day) for 10 days. 2. LOCAL: application of antibiotics using controlled release devices for 10 days (25% Tetracycline fibers).
    78. 78. D. Surgical approach: 1. • using abundant saline rinses at the defect, • barrier membranes, • close flap adaptation and • careful post-surgical monitoring for several months. • Plaque control is to be assured by applying chlorhexidine gels. 2. • Apical repositioning of the flap following osteoplasty around the defect.
    79. 79. Esthetic complications • Depends on patient s esthetic expectations and patient related factors(bone quantity and quality). • Depends on individual perceptions and desires
    80. 80. : Poor implant placement Deficiencies in the existing anatomy of the edentulous sites Crown form, dimension, shape and gingival harmony is not ideal Esthetic regions: high esthetic demands, thin periodontium, lack of hard and soft tissue support in the anterior esthetic regions
    81. 81. Reconstructive procedures to develop a natural emergence profile of the implant crown Appropriate treatment planning and implementation
    82. 82. Phonetic complications • Implant prosthesis with Unusual palatal contours ( Restricted or narrow palatal space) Spaces under and around the superstructure of implant Mostly observed in severe atrophied maxilla Management: implant assisted maxillary- overdenture
    83. 83. Postoperative maxillary sinusitis • Maxillary sinusitis can occur Contamination of the maxillary sinus with oral or nasal pathogens or via ostial obstruction caused by postoperative swelling of the maxillary mucosa, Non-vital bony fragments floating freely in the maxillary sinus. Lack of asepsis during sinus augmentation
    84. 84. (Timmenga et al., 2001) Preoperative evaluation of sinus clearance-related factors Postsurgery: a nasal decongestant (xylomethazoline 0.05%) and topical corticosteroid (dexamethasone 0.01%) to prevent postsurgery obstruction of the ostium Perioperative antibiotic prophylaxis (cephradine 1 g 3 times daily, starting 1 hour before surgery and continued for 48 hours after surgery)
    85. 85. Failed osseointegration • Osseointegration was originally defined as a direct structural and functional connection between ordered living bone and the surface of a load-carrying implant (Albrektsson et al. 1994). Osseointegration between an endosseous titanium implant and bone can be expected greater than 85% of the time when an implant is placed.
    86. 86. Factors Comments Implant failure Previous failure Surface roughness Surface purity and sterility Fit discrepancies Intra-oral exposure time Mechanical overloading Premature loading Traumatic occlusion due to inadequate restorations
    87. 87. Patient(local factors) Oral hygiene Gingivitis Bone quantity/quality Adjacent infection/inflammation Presence of natural teeth Periodontal status of natural teeth Impaction of foreign bodies (including debris from surgical procedure) in the
    88. 88. Patient( systemic factors) Vascular integrity Smoking Alcoholism Predisposition to infection, e.g. age, obesity, steroid therapy, malnutrition, metabolic disease (diabetes) Systemic illness Chemotherapy/radiotherapy Hypersensitivity to implant components
    89. 89. Surgical technique/environment Surgical trauma Overheating (use of handpiece) Perioperative bacterial contamination, e.g. via saliva, perioral skin, instruments, gloves, operating room air or air expired by patient
    90. 90. Conclusion Dental implant placement is not free of complications, as complications may occur at any stage. Careful analysis via imaging, precise surgical techniques and an understanding of the anatomy of the surgical area are essential in preventing complications. Prompt recognition of a developing problem and proper management are needed to minimize postoperative complications.
    91. 91. Thank you