Local Complications in Dental Implants Surgery

1. PREVENTION AND TREATMENT

2. DISTINCTION BETWEEN
 ACCIDENTS - events that occur during surgery
 COMPLICATIONS – all the conditions that appear
postoperatively
~early stage complications appear in the immediate
postoperative period & interfere with healing
~late stage: during the process of osseointegration.

3. EARLY STAGE COMPLICATIONS
INVOLVE : maxillary sinus or mandibular bone
soft tissues & nerve trunks adjacent
to the implant site.
•CAUSES - excessively traumatic surgical
approach
-bone overheating during osteotomy
-bacterial contamination of the host
site.

4. DURING FIRST FEW POST-OPERATIVE DAYS
-edema, exudate & pain.
CAUSES: bacterial contamination during surgery
~directly or indirectly.
PREVENTION- of the infection mainly depends on asepsis
-sterile working area
-disinfection of perioral skin with povidone
iodine & alcohol
-disinfection of oral mucosa with 0.2% Chx
(studies have shown reduction in infections 4.1% test group
8.7% control group by Chx use)

5. EDEMA
 ACCUMULATION OF EXCESS PLASMA FLUID
(transudate) in the interstitial spaces (at least 10%
increase)
 Edema is related to extent of surgical trauma & duration of
surgery .
 Negatively affects healing, and causes discomfort during
food intake & oral hygiene maintenance.
 Prevention - atraumatic surgical technique
- minimal tissue damage
- ice packs & administration of corticosteroids

6. ECCHYMOSES & HAEMATOMAS
 NOT COMMON
 CAUSES - long & complex procedures
- lack of patient compliance with the
instructions given for the postoperative period
-vessel fragility(esp. in elderly pt.)
-failure to discontinue anti-platelet
therapy before surgery
• MANAGEMENT- topical skin application of heparin
containing medications.

7. EMPHYSEMA
 Rare complication; from a sudden rise of the intra-oral
pressure. ie when the pt. sneezes
 CLINICALLY - swelling of half of face; extending
at times to neck & thorax
- crackling sound heard upon palpation
• MANAGEMENT-massages & compression with
ice packs .
• PREVENTION- avoid use of high velocity instruments to
prepare the bone bed or irrigation of the wound with
hydrogen peroxide.

8. BLEEDING
 Causes - failure to stabilize flap
-tearing of soft tissues
-masticatory trauma
-early temporization and inappropriately
modified temporary prosthesis.
• MANAGEMENT- compression & tamponade
with
surgical gauzes soaked in tranexamic acid.
- if bleeding persists, re-elevate flap, remove
clotted blood & place new sutures to immobilize the
soft tissue and promote clot formn. And stabilization.

9. FLAP DEHISCENCE
 Is the opening of the surgical wound edges exposing
implant head &/or surrounding bone tissue.
 Causes - thin mucosa
- failure to ensure passive re-approximation &
closure of flap margins (thus unable to counter
intramural mechanical stress- due to muscle and
bone interaction)
- insufficient or extensive tension on the
suture(leads to soft tissue necrosis)
- functional movements, mastication,
phonation or deglutition.

10. Causes contd..
- Previous radiation therapy which affects flap
vascularity
- Incomplete tightening of the cover screw (due to
presence of blood residues)
- Bone debris trapped under the periosteum
- Cigarette smoking & local effects of nicotine
(cytotoxic & vasoactive substances) & systemic
(altered granulocytes & T-cells), impaired production
of antibodies & vasomotor substances.

11. Treatment - based on extent of exposure
If small
If large
 no surgical correction, as
 removing the sutures &
the granulation tissue
which forms would
promote healing .
 granulation tissue
formation process lasting
>2 wks may require
refreshing the epithelial
wound margins
re-suturing.

12. Prevention of Dehiscence :
Careful preoperative assessment of the soft tissues, to
measure the amount of keratinized mucosa present &
planning of augmentation procedures as appropriate.
1.Minimally invasive flap elevation & reflection with
careful removal of any bone debris
2.Proper suturing
3.Sensible temporization with appropriate modifications;
rebasing & relining
4.Delaying the use of removable dentures until 2 wks after
surgery

13. SENSORY DISORDERS
 Results from injuries to the nerve trunk
 May lead to hyperesthesia, hypoesthesia or
anesthesia.
 SYMPTOMS- numbness, tingling, hot & cold, pain,
swelling, hardening, burning, loss of saliva, prickling,
tickle, electrical shock sensation, itch.
 lower jaw more affected - lower lip 54-64%, chin 4658%, gum tissues 32-45%, tongue 11-16%

14. Nature of damage
Reversible
 Compression by edema
or hematomas
 Excessive stretching
(>8% elastic limit) of
the mental nerve
during flap reflection
Permanent
 Injuries to inferior
alveolar nerve or
mental nerve during
osteotomy leads to
permanent sensory
alteration along with
hyperalgesia.

15. Diagnosis
Early stage
 Immediately after injury
occurs
 Assessment of symptoms
 X-rays performed
 No radiographic changes wait & see attitude is
advisable since the
symptoms may result
from
"stunned nerve syndrome"
(neuropraxia)
Late stage
 When symptoms persist or
worsen
 Clinical investigationsmechanoreceptive, thermal,
electric,nociceptive &
chemical tests repeated
monthly, gustatory
sensitivity tests
 Lab tests -blink reflex test,
Computerised tomography,
nuclear magnetic resonance

16. Treatment
Immediate postoperative
period
 Combination drug
therapies with
NSAIDs, cortisones,
proteolytic enzymes,
antibiotics & vit C & E
- to reduce nerve trunk
compression by edema
or hematomas
First month after surgery
 To promote nerve regeneration -
vit C & D, vasodilators & ozone
therapy (to prevent ischemia),
magneto therapy, low level laser
therapy & transcutaneous
electric nerve stimulation
(TENS)
 nerve reconstruction1)neurorrhaphy
2) grafting
3) tubulization

17. Late: MAXILLARY SINUSITIS
 As a result of bacterial contamination during surgery
or healing for wound dehiscence or implant
placement into sinus
 ACUTE CASES : pain, edema , swelling, reddened
soft tissues
 CHRONIC CASES: massive proliferation of mucosa,
thickening of membrane, polypoid masses filling the
sinus,decrease air in sinus and antral content become
radiopaque

18. Treatment
 Systemic therapy- antibiotics, Chx mouthwashes,
saline irrigation through nasal orifice & use of nasal
decongestants
 If infection worsens or a dislodged implant in sinus radical revision surgery of sinus & the antral mucosa
completely removed.
 Prevention - screening patients prior to surgery for
sinustis or predisposing factors
- prophylactic antibiotic therapy
-asepsis

19. MANDIBULAR FRACTURES
 Rare - occur during osseointegration, after restoration or
as a result of trauma.
 Cause unknown; but fracture lines consistently pass
through implant sites , as stresses converge & loss of bone
density occurs .
 Clinical signs : pain, swelling, impaired function & fistulae
in fracture area
 Diagnosis - clinical evaluation: movement of fractured
segment, crackling sounds, signs of infection
-radiograph: radiolucent area through implant site

20. Treatment
 Aligned fractures : antibiotic therapy +soft diet
 Mal-alinged fractures : reduction & immobilization
Prevention
• Bone should be 7mm in height & 6mm in width ,
•
•
•
•
if not ridge expansion or augmentation
Avoid preparation of multiple bone beds
5mm of hard tissue left between two sites
Avoid overscrewing of implant
Keep mandible at rest during healing

21. FAILED OSSEOINTEGRATION
 Diagnosed at phase II surgery or restoration
 Results in loss of implant
 Causes: reduced healing, occlusal loading during
osseointegration, bone overheating(>47°C for 1min;
radiographically visible after 2-4 wks)
 Diagnosis: loosened implant & muffled sound upon
percussion
 Radiographically, radiolucent margin around implant
 Treatment : removal of implant & debridement of the
area

22. BONE DEFECTS
Can be horizontal or vertical
CAUSES: 1. Direct trauma to bone or insult to
periosteum (reduced vascularity)
2. Decreased bone density
3. Implant placement into fresh extraction site
4. Wrong inclination of the implant
5. Excessive torque during insertion
6. Thin alveolar crest
7. Wound dehiscence during healing
8. Perforation of mucoperiosteum
9. Postoperative infection

23. Diagnosis
 Patients are asymptomatic, thus radiographic examination
of crestal bone-implant interface.
Treatment:
• vertical defect
a) <2mm -horizontal osteotomy
b) >2mm- autologous bone graft ; if bone loss
>25% grafting + membrane
uncovering of implant postponed by 2- 4months

24. Treatment contd..
 Horizontal defect
a) small- apical repositioning of soft tissues
b) large - autologous graft + membrane
uncovering of implants postponed by 3-4mnths
prevention
• Plan treatment according to quality & quantity of bone
present

25. PERIAPICAL IMPLANT LESION
Is a pathological area of osteolysis at the apex of an
osseo-integrated implant
Cause: 1) accidental sectioning of the neurovascular
bundle
2) pre-existing bone infection
3) foreign bodies or root fragments
4) sinus infections
5) contamination of implant
6) compression of bone debris , causing
ischemia-necrosis & bone sequestration.

26. Infection
MAIN CAUSES:
CONTAMINATION OF RECENTLY INSERTED IMPLANTS BY PATHOGENIC
MICROFLORA. IT MAY BE FAVORED BY PRESENCE OF NECROTIC ANT
TRAUMATIZED BONY TISSUE AND/OR IMPAIRED HOST MECHANISM.
C/F – EDEMA , SWELLING , PURULENT EXUDATE, PAIN ON PALPATION OR
FISTULAE.
RADIOGRAPHIC FEATURE- MARKED BONE RESORPTION.
TREATMENT: IF BONE IS NOT INVOLVED, A FLAP IS ELEVATED TO DRAIN
THE ABSCESS AND REMOVE GRANULATION TISSUE.
FOLLOWED BY SALINE IRRI.& ADM-LOCAL ANTIBIOTICS
IF BONE RESORPTION+, A GUIDED BONE REGENERATION PROTOCOL WILL
BE FOLLOWED.
POSTOP- ANTIBIOTIC THERAPY: IN BOTH THE ABOVE CASES
AMOX+ CLAVULANIC ACID- 2G+METRON- 750MG & .12% CHX FOR ORAL
HYGIENE.

27. Conclusions:
 Local complications arising during the implant
surgery are the main determinants of the outcome of
the entire rehabilitation program.
 Hence, the prevention of the complications sh be our
main objective.
 Therefore, careful clinical and radiographic
examination, accurate treatment planning, proper
planning of procedures, use of proper surgical
techniques, appropriate instruments and correct
management of healing and osseointegration are all
the important aspects in preventing the
complications.