a brief discussion of common surgical complications that occur during and after implant surgery.

1. Complications and their
management in implant
dentistry
Presented by- Shashi kiran
18/7/19

2. Contents
• Classifications
• Intraoperative complications
• Postoperative complications
• Complication prevention
Avoiding Complications in oral implantology. Carl E Misch 2

3. Complication Classification
• Clavien et al proposed a classification of complications, which has subsequently
been used in the medical literature for outcome assessment.
• However, this classification may not be the most practical for the assessment of oral implantology
complications.
• • Grade 1: Any deviation from the normal postoperative course that does not
require pharmacologic intervention (i.e., pain, swelling)
• • Grade 2: Any deviation from the normal postoperative course that does require
pharmacologic intervention (i.e., infection)
• • Grade 3: A deviation that requires surgical intervention (i.e., incision and
draining)
• • Grade 4: Life-threatening complication requiring hosptitalization (i.e., sublingual
hematoma)
Avoiding Complications in oral implantology. Carl E Misch 3

4. Minor vs. Major
• A minor complication is self-limiting and usually of short duration,
with no permanent or lasting deficits. (e.g., swelling and bruising).
• A major complication is a more serious complication that is longer
lasting, potentially permanent, with associated possible morbidities
(e.g., infection, nerve impairment).
Avoiding Complications in oral implantology. Carl E Misch 4

5. Unavoidable vs. Avoidable
• An avoidable complication is a complication such as a nerve impairment caused
by placing an implant in the mandibular canal, without the use of a CBCT scan to
give the clinician an accurate representation of the proper nerve location.
• An unavoidable complication is a complication that cannot be avoided or
preventable in most instances and is not directly a result of negligence of the
implant clinician.(e.g., nerve impairment secondary to administration of inferior
alveolar nerve block).
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6. Reversible vs. Irreversible
• Reversible complications are complications that usually resolve on
their own and have no associated long-term morbidity (e.g.,
improper angulation upon implant placement after the first drill
osteotomy, which may be corrected easily).
• Irreversible complications are complications that are permanent and
cannot be reversed, thus having increased severity and consequences
(e.g., mandible fracture after implant placement)
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7. Intraoperative complications
• Bleeding
• Infection
• Nerve injuries
• Broken burs
• Malpositioning of implants
• Overpreparation of Final Drill
• Aspiration of instruments
• Cortical plate perforations
• Injury to adjacent teeth
• Overheating the Bone
• Air emphysema
• Local anesthesia related
Avoiding Complications in oral implantology. Carl E Misch 7

8. Bleeding
Bleeding According to Source
• Arterial hemorrhage: bright red,
spurting/pulsatile
• Venous hemorrhage: dark red,
continuous
• Capillary hemorrhage: bright red,
continuous
• Primary hemorrhage: This type of
bleeding occurs during surgery and is
usually the result of the incision,
retraction, or preparation of the soft
or hard tissue
• Reactionary hemorrhage: occur
within hours after surgery. most likely
occurs in patients who exhibit
systemic bleeding issues, are on
anticoagulant therapy, or experience
postoperative trauma to the surgical
area that disturbs the clot
• Secondary hemorrhage: This type of
bleeding occurs 7–10 days after
surgery and is most likely the result of
an infection.
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9. Factors Contributing to Intraoperative Bleeding
• Hypertension
• Medications- anticoagulants, antiplatelet drugs, nsaids
• Systemic bleeding disorders- hemophillia, von willebrands, factor
deficiencies.
• Liver Disorders. Liver disease (e.g., cirrhosis, acute liver failure) is
associated with many significant abnormalities of the coagulation system
Avoiding Complications in oral implantology. Carl E Misch 9

10. Techniques to Decrease and Control Bleeding
Mechanical Methods
• Positional Changes- Repositioning the patient to an upright position (head above
the heart) will not stop the bleeding; however, it will significantly decrease the
hemorrhage (studies have shown a decrease up to 38%)
• Direct Pressure- Pressure or compression directly on the blood vessel will allow
for platelet aggregation and initiation of the coagulation cascade. Pressure may
be applied manually or by the patient biting forcefully on a gauze dressing.
Pressure should be maintained for at least 3 to 5 minutes to allow the formation
of a blood clot.
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11. • Suturing- The suture is placed by entering the tissue at least 4 mm from the
bleeding vessel, 3 mm below the vessel, and 4 mm exiting the tissue. This will
ligate or occlude the vessel as long as it is placed proximal to the bleeding area.
A figure-eight suture technique is ideally utilized
• Clamped Vessel With Hemostat Forceps- When local measures are not
successful in controlling bleeding, a hemostat may be utilized to clamp the
blood vessel.
• Thermal Techniques- electrocautery, Lasers
• Pharmacologic Techniques- Epinephrine. When locally placed, epinephrine will
reduce bleeding, slow the absorption of the local anesthetic, and prolong the
anesthetic and analgesic effect
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12. • Tranexamic Acid Solution- Tranexamic
acid 4.8% is an antifibrinolytic oral rinse
that facilitates clot formation by
inhibiting the activation of plasminogen
to plasmin
• Topical Hemostatic Agents- Absorbable
topical hemostatic agents are used when
conventional methods of hemostasis are
ineffective. These agents may be placed
directly into the bleeding site to decrease
bleeding during the procedure or during
the postoperative interval (collagen,
gelatin, cellulose, chitosan based,
beeswax)
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13. Infection
Factors Associated With Increased Risk of Infection for Dental Implant Procedures
• Systemic Factors • Diabetes • Long-term corticosteroid use • Smoking •
Immunocompromised systemic disorders • Malnutrition, obesity • Elderly
population
• Local Factors • Use/type of grafting material (autogenous, allograft, alloplast) •
Periodontal disease • Tissue inflammation • Odontogenic infections • Ill-fitting
provisional prosthesis • Incision line opening • Inadequate hygiene
• Surgical Factors • Poor aseptic technique • Skill/experience of the surgeon •
Increased duration of surgery • Wound contamination during surgery • Foreign
body (implant)
Avoiding Complications in oral implantology. Carl E Misch 13

14. Signs of Infection
Vital Signs
• • Temperature: >101°F (38°C) (normal: 98.6°F [37 °C])
• • Pulse Rate: >100 beats/min (normal: 60–100 beats/min)
• • Blood Pressure: Systolic will be elevated if there is pain/anxiety
• • Respirations: >18 breaths/min (normal: 14–16 breaths/min)
• Mild Infection. Normal vital signs with slight elevation of temperature. Usually
associated with one of the following: • Fatigue: extreme tiredness • Malaise: a
general feeling of discomfort, illness, or uneasiness • Lethargy: lack of energy or
enthusiasm
• Severe Infection. Elevated pulse, blood pressure, and respirations along with
temperature and any of the following- Trismus, Lymphadenopathy, dysphagia
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15. Prevention and Treatment of Infection
• Antibiotic therapy utilized in implant dentistry may be classified as either
prophylactic (to prevent infection) or therapeutic (to treat infection).
• Prophylactic Antibiotics- Amoxicillin is the drug of choice. If the patient is
allergic, alternative drugs are: Cephalexin (nonanaphylactic allergy to penicillin)
Clindamycin (anaphylactic allergy to penicillin)
• The recommended treatment for intraoral infections associated with implant
therapy include the following:
• 1. Surgical drainage- This procedure includes the incision of the abscess or
cellulitis, which results in the removal of the accumulated pus and bacteria from
the underlying tissue.
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16. • 2. Systemic antibiotics- Amoxicillin (500 mg)/two immediately, then one tablet
three times daily for 1 week; or if penicillin allergy exists Clindamycin (300
mg)/two immediately, then one tablet three times daily for 1 week.
Use of Chlorhexidine in Oral Implantology
• Patient presurgical rinse. It can be used in the aseptic protocol before surgery for
reduction of bacterial load
• Surface antiseptic. It can be used in the intra- and extraoral scrub of patient,
scrubbing of hands before gowns and gloves
• Postsurgical rinse. Patient should rinse twice a day until incision line closure
• Periimplant maintenance on daily basis. Treatment of postoperative infections.
Avoiding Complications in oral implantology. Carl E Misch 16

17. Sterile Technique
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18. Nerve injuries
Etiology
• Administration of Local Anesthesia- needle, hematoma, toxicity
• Soft Tissue Reflection: may occur during the reflection,
retraction, or suturing of the soft tissue.
• Implant Drill Trauma- Drill Encroachment, partial penetration,
transection
• Anesthesia Total Loss of Feeling or Sensation
• Dysesthesia Abnormal sensation that is unpleasant
• Paresthesia Abnormal sensation that is not unpleasant
• Hypoesthesia Decreased sensitivity to stimulation
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19. Management
1. Nerve Impairment at Time of Surgery
• During surgery, if known traction or compression of the
nerve trunk has occurred, the topical application of
Dexamethasone may be used to minimize deficits. Upon
removal of an encroaching implant on the mandibular
canal, 1–2 mL of the intravenous form of Dexamethasone
(4 mg/mL) is topically applied).
• This direct steroid application will reduce neural
inflammation and may enhance recovery from
neurosensory deficits.
• Studies have shown no morbidity associated with the
topical application of glucocorticoids at the injury site and
postsurgical recovery has also been shown to improve
significantly..
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20. Avoiding Complications in oral implantology. Carl E Misch 22
• Nerve impairment post surgically

21. Bur “Stuck” in Bone During Osteotomy
• Often in hard bone (≈D1–D2 bone), if the handpiece is stopped with the surgical drill in
the bone, it may be difficult to remove out of the osteotomy
• Prevention: in dense bone small (minimal) increments of bone should be removed at a
time, which will result in less stress to the bone and will allow for ease of widening the
osteotomy. Also, by using intermediate burs (more burs close in diameter), smaller
amounts of bone are removed at a given time, decreasing the possibility of burs being
lodged in the bone
• Treatment: If a bone drill becomes lodged in the bone during preparation, the hand
piece should not be wiggled back and forth to disengage the drill. This may increase the
size of the bone preparation, cause injury and necrosis to the bone, or separate the drill
above or below the bone. Instead, the drill is disengaged from the handpiece and gently
rotated counterclockwise with forceps or rongeurs.
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22. Over-preparation of Final Drill
• Etiology- The final drill is the most critical surgical step in the osteotomy preparation. The
bone surrounding this drill will be in direct contact with the implant. When the final drill
preparation is not precise, the implant-bone region may be irregular with gaps that may
decrease initial stability and lead to early implant failure
• Prevention A constant pressure and angulation is used with the final drill to ensure that
a precise, round osteotomy is prepared. The most important factor is the use of the final
drill only once to avoid over preparation, most importantly in less dense bone
• Treatment If overpreparation of the osteotomy site occurs, clinical evaluation should be
completed to determine if mobility of the implant exists.
• Remove Implant, Place Wider Implant.
• Remove Implant, Graft, Let Heal.
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23. Facial Dehiscence After Implant Placement
• Etiology Bony defects at the crest after implant placement will
usually result in lack of available bone width at the ridge level
• Prevention All ridges should be modified to obtain a division A
bone (e.g., >6 mm width and >12 mm of bone height) before
osteotomy initiation. After implant placement, 1.5 mm of facial
bone should be present or the area should be grafted.
• Treatment After implant placement, if there exists less than 1.5
mm of bone on the facial aspect of the ridge, the site may be
grafted with autogenous bone (ideally). The autogenous bone
may be obtained from fragments gathered from the flutes of the
surgical drills during the osteotomy preparation
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24. Loss of Facial Plate When Placing an Implant
• Etiology: When compromised width of bone exists, the
trauma of the osteotomy or the placement of the implant
may fracture or “pop off” the buccal plate. This is most
likely the result of the buccal plate being thinner than the
lingual plate.
• Prevention- The osteotomy preparation should be in one
plane, and care should be exercised to not deviate from
the original angulation.
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25. Treatment-
• Loss of Entire Buccal Plate or if mobility of the implant exists, the ideal treatment
should include grafting then allowing for sufficient healing before implant
placement.
• Partial Buccal Plate Still Intact and If no mobility of the implant is present the
facial area can be grafted, ideally with autogenous bone from the osteotomy site
Avoiding Complications in oral implantology. Carl E Misch 27

26. Overheating the Bone
• Etiology The amount of heat produced in the bone is directly related to the
amount of bone removed by each drill. Lack of gradual increase in drill diameter.
• Prevention- Intermediate Drills. Gradual increases in drill diameter reduce the
amount of pressure and heat transmitted to the bone. Copious Amounts of
Saline.
• Bone Dance. When preparing the osteotomy, small increments of bone should be
removed, and by using the up-and-down motion of the drill, irrigation may enter
the osteotomy site easier
• Use of Sharp, New Drills
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27. • Drill Speed. Osteotomy preparation at higher speeds with sharp drills elicits less
risk of osseous damage and a decreased amount of devitalized zone adjacent to
the implant.
• Treatment If known excess heat generation occurs during implant placement,
ideally the implant should be removed, regional acceleratory phenomenon (RAP)
initiated, and the site grafted for future implant placement. If bone width is
available after sufficient RAP is completed, a wider implant may be placed
Avoiding Complications in oral implantology. Carl E Misch 29

28. Swallowing/Aspiration of Implant
Components
• Etiology Because of the small size of abutments, screws, drivers, and other
implant components, a significant risk for aspiration exists.
• This may occur during any dental implant procedure, including the surgical and
prosthetic phases.
• There are two possibilities: the patient may swallow the foreign object into the
stomach or aspirate the foreign material into the lungs.
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29. • Swallow. If the object is swallowed, usually the patient will be asymptomatic.
However, depending on the shape and size of the object, it may need to be
removed because of the complication of blockage or not passing through the
gastrointestinal system.
• Aspiration. The object may end up in the lungs, in which case the patient will be
symptomatic. The patient will exhibit signs of coughing, wheezing, hoarseness,
choking, stridor, or cyanosis.
• Prevention- Floss ligatures to all possible implant components • Use throat packs
(4 × 4 gauze) or pharyngeal screens • High-vacuum function
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30. Treatment
• If an instrument is lost in the mouth, the patient should first be instructed to not sit
straight up because this will ensure the swallowing or aspiration of the instrument.
• The patient should turn to the side and attempt to “cough” the instrument up.
• If the instrument has been swallowed into the stomach, usually the patient will exhibit
no symptoms. If the patient has aspirated the instrument, this will most likely be
accompanied with coughing, wheezing, pain, and cyanosis.
• This may be life-threatening and should be treated accordingly as a medical emergency.
In all swallowing/aspiration situations, the patient should be referred to their physician
or emergency room for an immediate chest x-ray.
• If the instrument has been aspirated, it is usually located in the right bronchus because
the right main bronchus has a more acute angle than the left. Rigid bronchoscopy is
usually used for the removal of the instrument under general anesthesia
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31. Air Emphysema
• Etiology: Because of the attachment apparatus difference between implants and
teeth, air extruded into the sulcular area around implants may lead to air
emphysema.
• The two most common ways for this to occur is the use of an airdriven handpiece
or an air-water syringe in which air is forced into the sulcular area.
• Symptoms will include swelling that increases over time with a “crackling” feeling
with pain. Crepitus to palpation will confirm the diagnosis of air emphysema. The
patient will usually be apprehensive with a feeling of difficulty in breathing
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32. • Prevention: When placing implants, modifying abutments with the mouth, or
removing bone around an implant body, an electric handpiece should always be
used (i.e., never use a air-driven handpiece).
• Additionally, an air-water syringe should never be used to place air into the
sulcular area parallel to the long axis of the implant.
• Treatment- Patients with significant emphysema should be monitored closely
prior to discharge for respiratory or cardiac distress. Treatment should include
supportive therapy with heat and analgesics.
• Antibiotic therapy should always be given because infection may result from
bacteria being induced into the fascial spaces with resultant cellulitis or
necrotizing fascitis. Resolution usually occurs in 4 to 7 days with minimal
morbidity.
Avoiding Complications in oral implantology. Carl E Misch 34

33. Insufficient Implant–Root Apex Distance
• Etiology: Implants placed too close to an adjacent tooth root are
usually the result of poor treatment planning (inadequate space),
poor surgical technique (improper angulation), or placement of
too wide of an implant body. This may occur when there are root
dilacerations of an adjacent tooth
• Complications- Damage to Adjacent Periodontal Ligament, Loss of
Implant (Implants that are placed too close to an adjacent tooth
may fail due to infection or bone resorption), Loss of Tooth (the
adjacent tooth may be irreversibly traumatized and may be lost to
a fracture or to internal or external resorption)
• Prevention- Ideal Position. The ideal position is to maintain at
least 1.5 mm from the adjacent tooth root or tooth structure
Avoiding Complications in oral implantology. Carl E Misch 35

34. • Proper Treatment Planning, Use of Study Casts, 3D imaging,
Treatment
• Initial Placement. If there is insufficient space between an implant and a natural
tooth, the implant should be removed and repositioned, especially if the
adjacent tooth is symptomatic. If space is compromised (less than 6mm)the roots
should be repositioned via orthodontics or treatment plan changed to a different
type of prosthesis.
• Past Placement. If an implant has been restored and root approximation (less
than 1.5mm) exists, the tooth/implant should be monitored on a regular basis
and the patient informed of the possible morbidity. If symptomatic or
radiographic pathology is present, the implant should be removed and
repositioned along with vitality testing of the tooth
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35. Lack of Implant–Coronal Distance
• Etiology: occurs most likely from poor initial osteotomy
positioning, poor treatment planning, or the use of too large of
an implant body
• Complications- Interproximal Bone Loss, Compromised
Emergence Profile, Hygiene Difficulties, Reduced Papilla
Height.
• Prevention- Treatment Planning, Surgical Adjuvants.(templates
and guides)
Avoiding Complications in oral implantology. Carl E Misch 37

36. Treatment
• Initial Placement. If the position of the implant is less than 1.0 mm from the
adjacent clinical crown, removal and reposition of the implant should be
completed. If the implant is positioned 1.1 to 1.5 mm from adjacent tooth,
removal or modification (enameloplasty) of the adjacent tooth may be
completed, as long as irreversible damage to the tooth is not done.
• Past Placement. the tooth/implant should be monitored. If symptomatic, the
implant should be removed and repositioned along with vitality testing of the
tooth.
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37. Inability to Obtain Mandibular Block
• In edentulous mandibles or patients
being treated with sedation, this may
be difficult, and alternative anesthesia
techniques are warranted
• require the use of reference points
(occlusal plane), which are not
present in edentulous patients.
• Additionally, many dental implant
patients are sedated, which results in
difficulty for the patient to open fully
for the injection.
Prevention
• The implant clinician must understand
and utilize profound, alternative
anesthesia techniques such as the
Akinosi technique.
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38. Post operative complications
• Swelling
• Ecchymosis
• Trismus
• Post surgical pain
• Post operative bleeding
• Post surgical nausea
• Titanium
Allergy/Hypersensitivity
• Fractured Mandible After
Implant Placement
• Partial Cover Screw Exposure
• Fractured Implant
• Displacement or Migration
Complications
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39. Post-operative Swelling
• Two variables determine the extent of edema: (1) the
amount of tissue injury is proportional to the amount of
edema; (2) the more loose the connective tissue at the
surgery site, the more edema is most likely to be
present
Prevention
• good surgical technique must be used with minimal
tissue trauma.
• excessive retraction, and long surgical duration, which
will all contribute to increased inflammation after
surgery.
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40. • Postoperative prophylactic medications such as ibuprofen (nonsteroidal
antiinflammatory drugs [NSAIDs]) and glucocorticosteroids (steroids) are utilized
as prophylactic medications, which counteract the negative effects of the edema
cascade
• Cryotherapy- Cold dressings (ice packs) should be applied extraorally (not directly
on skin: place a layer of dry cloth between ice and skin) over the surgical site for
20 minutes on/20 minutes off for the first 24–36 hours
• Treatment Swelling is self-limiting and, once it occurs, it is usually difficult to treat
(time-dependent). The above mentioned medications/therapy (Decadron,
NSAIDs, cryotherapy) will help to reduce postoperative inflammation
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41. Ecchymosis (Bruising)
• Ecchymosis is subcutaneous extravasation of blood within the
tissues, which results in discoloration of the skin from the seepage
of blood in the tissues.
• Moderate bruising should be expected after dental implant surgery,
especially after longer, more invasive surgeries. Female and elderly
patients are more susceptible to bruising
• Prevention: Unfortunately, even with gentle handling of tissues and
good surgical technique, ecchymosis may be unavoidable. To
minimize ecchymosis, avoid postoperative aspirin, herbal remedies,
and food supplements that may increase bleeding
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42. Treatment
• Ecchymosis is self-limiting and usually resolves without treatment. However, the
patient may treat the ecchymosis in the following ways:
• Rest/avoid strenuous activity: promotes tissue healing and decreases
inflammation.
• Elevation: helps decrease inflammation, facilitates proper venous return, and
improves circulation to the site.
• Analgesics: helps reduce pain associated with the onset of ecchymosis.
• Sun exposure: inform patient to avoid sun exposure to the area of bruising as
excessive sunlight may cause permanent discoloration.
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43. Trismus
• Etiology: The most likely etiologic factor is local anesthetic, secondary to an inferior
alveolar nerve block that penetrates the medial pterygoid muscle. Also, complicated or
prolonged surgical procedures that require full-thickness mucoperiosteal flaps with
resultant edema can lead to trismus
• Prevention- When placing implants, especially in the posterior region, care should be
taken to minimize excessive opening of the patient to where spasm of the muscles of
mastication would result. Bite blocks, short duration treatment, and sedation may
decrease the possibility of trismus complications.
• Treatment Usually trismus will resolve with time; however, patients should maintain a
soft diet and minimize overactivity. Additional treatment includes the use of physical
therapy, passive range of motion exercises, splint therapy, and medications such as
NSAIDs, muscle relaxants, and steroids (Decadron).
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44. Postsurgical Pain
• Prevention- 1. Good surgical technique 2. Surgery duration not to exceed
patient's tolerance 3. Postoperative long-acting anesthetics 4. Adequate
postoperative pain control and instructions 5. Limitation of patient activities post-
operatively
Control of Postoperative Surgical Pain.
• 1. The first step is to maximize the use of NSAIDs (acetaminophen, ibuprofen) for mild to
moderate pain. Adjuvant medications such as glucocorticoids and cryotherapy are often
suggested.
• 2. When moderate pain is expected or persists, an opioid (hydrocodone, codeine) should
be added to the NSAID. Glucocorticoids and cryotherapy are encouraged.
• 3. Moderate to severe pain that is expected or persists should be treated by increasing
the dosage of the opioid. Glucocorticoids and cryotherapy are of particular benefit when
not contraindicated.
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45. Post-surgical bleeding
• Patients should be cautioned on the potential for bleeding during the first 24
hours
• Recommendations should be given to minimize wearing an interim prosthesis
because this may result in increased bleeding.
• For significant or prolonged bleeding, the patient should be instructed to contact
the doctor.
• The patient should also be instructed not to use a straw when drinking fluids
because this may create a negative pressure and increase bleeding. Also,
spitting and vigorous rinsing may open the surgical wound and cause bleeding
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46. • Patients should be instructed to limit their activities for a minimum of 24 hours
depending on the extent of the surgery.
• The head should be elevated as much as possible during the daytime hours and
the use of two pillows (i.e., elevate head) during sleeping will reduce secondary
bleeding episodes.
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47. Nausea After Surgery
• The etiology of nausea after surgery may be a direct result from prophylactic
medications (Augmentin, Clindamycin) or the swallowing of excessive amounts
of blood, especially after longer procedures.
• Prevention- . Nausea can be reduced by preceding each pain pill with a small
amount of soft food, and taking the medication with a large volume of water.
Additionally, minimizing the swallowing of excessive amounts of blood will
reduce the possibility that the blood will irritate the stomach mucosa (effective
suctioning)
• Treatment If nausea is extensive after surgery, OTC antiemetics may be used or
prescription medications (e.g., ondansetron [Zofran] 4-mg sublingual tablets) may
be prescribed
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48. Titanium Allergy/Hypersensitivity
• Etiology- Titanium alloy dental implants have
been shown to contain many “impurities” that
may trigger type IV hypersensitivity reactions
• Prevention- Thorough medical history involving
any past history of titanium hypersensitivity
• Treatment When titanium hypersensitivity is
suspected, the implants should be removed and
the patient should be referred to their physician
for appropriate testing
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49. Fractured Mandible After Implant Placement
Etiology
• Fractured mandibles most likely occur from attempting to place implants in
patients with severely resorbed ridges, Patients who are predisposed to fractures
include those with highly excessive occlusal forces, or with division C−w and D
mandibles
• Additional causes of mandibular fractures include placing implants that are too
wide or too long, which compromises the host bone and requires excessive
tightening of implants.
• Late (after surgery) mandibular fractures most likely are caused by an increased
stress at the implant site. Repeated functional forces placed on the implant
eventually lead to the fracture of the bone
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50. • Prevention The prevention of mandibular fractures includes proper treatment
planning and diagnosis, which involves the contraindication of implants placed in
division D mandibles. Division D patients should be referred for possible iliac crest
grafting.
• Treatment The treatment of a fractured mandible after implant placement is
referral to an oral and maxillofacial surgeon for definitive care and possible
removal of the offending implants, along with reduction and stabilization of the
mandible
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51. Partial Cover Screw Exposure
• Etiology • Incision line opening • Excess tension on the incision line • Thin tissue (thin
biotype) • Interim prosthesis pressure • Immediate implant placement • Implant
design—high surgical cover screw
• Prevention To prevent premature opening, tension should be released from the incision
line. This will allow for tension-free closure and minimal pressure on the incision line.
The interim prosthesis should be adjusted to have no direct contact on the surgical site
• Treatment The implant should be uncovered (tissue punch bur) and the smallest
permucosal extension (in height) should be used. Ideally, the permucosal extension
should be 1 mm above the tissue height. No attempt should be made to resuture and
obtain primary closure. The patient should be instructed on proper hygiene to include
gentle brushing of the abutment along with the use of chlorhexidine
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52. Fractured Implant
Etiology
• Cantilevers, angled loads, and parafunction increase the risk of
fracture.
• Typical mechanical failures are due to either static loads or
fatigue loads.
• Static load (i.e., one load cycle) failures cause the stress in the
material to exceed its ultimate strength after one load
application.
• Fatigue load failures occur if the material is subjected to lower
loads but repeated cycles of that load
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53. • Prevention: a titanium alloy implant should ideally be used. Parafunctional habits
should be addressed with occlusal guards, and an ideal occlusal scheme.
• Treatment: The ideal treatment for a fractured implant includes the removal and
possible replacement of the implant. Alternative treatments include
modification of the prosthesis to not include the implant and possible
modification of the fractured implant (cementable abutment).
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54. Displacement of Implants: Maxilla
• The timing of implant displacement into the maxillary sinus proper has been
shown to range from the time of surgery to 10 years after prosthetic
rehabilitation.
• When implants are determined to be displaced into the maxillary sinus,
immediate evaluation and removal should be rendered.
• If left untreated, the displaced implants may become calcified (antrolith) or
migrate into adjacent anatomic areas.
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55. Maxillary Sinus.
• All case reports discussing the migration of implants
(either early or late migration) find that they originate
in the maxillary sinus because of its anatomic location
with respect to the maxillary posterior region. After
displacement into the maxillary sinus, the dental
implants have been reported to migrate to various
anatomic areas
• The physiologic action of the maxillary sinus will
transport the dental implant into the ostium area,
most likely blocking the area and causing nonpatency.
Nonpatency of the maxillary ostium will lead to
infection or cause the implant to erode through the
ostium to other anatomic areas
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56. • Nasal Cavity. Dental implants may migrate from the
maxillary sinus into the nasal cavity via extrusion
through the ostium or erosion through the medial wall
of the sinus (lateral wall of the nasal cavity).
• Ethmoid Sinus. Dental implants may migrate to the
ethmoid sinus via the ostium or erode through the
superior wall of the sinus
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57. • Orbital Area. The floor of the orbit coincides with the roof (superior) wall of
the maxillary sinus. Implants may migrate from the maxillary sinus into the
inferior wall of the orbit (superior wall of maxillary sinus)
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58. Etiology (early- at the time of surgery)
• Poor Bone Quality. Because of the poor bone quality, the bone lacks density and
strength and cannot maintain rigid fixation of the implant
• Poor Surgical Technique. Because of the poor bone quality, if the osteotomy is
prepared with a conventional drill sequence (e.g., routine, standard
manufacturer's protocol), overpreparation of the osteotomy site will result.
Because of the overpreparation, there will be insufficient bone at the crestal level
to maintain rigid fixation and migration may occur.
• Immediate Implant Placement. This is most critical in the first molar area, where
the defect from the extraction results in minimal bone to maintain stability of the
implant.
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59. Etiology: Late (After Surgery) Migration
• Negative Pressure. When initial fixation of the implant is absent, because of the
compromised bone implant contact (BIC), changes in intrasinus and nasal air
pressure may produce a suction effect, causing a negative pressure. This may
result in the displacement of the implant into the maxillary sinus
• Autoimmune Reaction. Many authors have discussed autoimmune reactions
with the dental implant, which result in bone loss around the implant, loss of
integration, and intrusion into the maxillary sinus
• Occlusal Overloading. Because of the poor bone quality in the posterior maxilla,
excessive occlusal force will result in bone loss or loss of fixation of the implant.
• Peri-Implantitis. If peri-implantitis around a maxillary posterior implant is left
untreated, loss of fixation may result, which will lead to insufficient fixation.
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60. Prevention
• To prevent displacement and migration of implants into the maxillary sinus, ideal
treatment planning along with surgical technique should be adhered to.
• A comprehensive preoperative evaluation of the posterior maxilla should be
completed and the inherent unfavorable anatomic and possible pathologic
conditions should be addressed when treatment planning in this area
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61. Treatment
• Treatment of migrated or displaced implants includes the immediate removal,
which usually necessitates referral to an oral and maxillofacial surgeon (OMFS) or
otolaryngologist (ENT).
• The most common approaches for removal of implants include the traditional
Caldwell-Luc procedure, intraoral approach, or a transnasal approach with
functional endoscopic sinus surgery
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62. Conclusion: Complications Prevention
• Increase Education: Implant dentists must have a firm and deep understanding about a wide
spectrum of subjects ranging from CBCT interpretation and diagnosis, treatment planning, hard
and soft tissue management, prosthetic design, esthetic presentation, pharmacology, surgical
principles, and numerous other subjects.
• Seek Accreditation: It is also highly recommended for clinicians to test themselves by seeking
accreditation with the various implant boards and groups. This higher level of accreditation is vital
for the implant dentist to perform because it helps to build a deeper understanding and greater
mastery of the various aspects of oral implantology
• Literature Review Updates: Another way for the prevention of implant complications is to
become familiar with the process of literature review. A good piece of advice for the avoidance of
complications is to “not be the first, nor the last” to the latest trends or ideas in the field
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63. • Patient Information: The patient should be informed of the advantages, disadvantages, risks, and
potential complications regarding each treatment option
• Do Not Rush Treatment: During treatment, the clinician can avoid substantial complications by
avoiding the urge to rush through the proper sequence and timelines for implant dentistry
• Treat for the Long Term, Not the Short Term
• Follow-Up Care: The last aspect of complication prevention is a policy of strong follow-up care.
Keeping communication open with the patient through all the phases of treatment is vital to
staying on top of any potential complication issues.
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64. Thank you….
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