DENTAL IMPLANT- COMPLICATIONS‘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.+ 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.* 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)‘al complications ind po implant surgery. Early-stage complications * Infection + Edema * Ecchymoses and haematomas + Emphysema * Bleeding + Flap dehiscence * Sensory disordersLate complications + Perforation of the mucoperiosteum + Maxillary sinusitis * Mandibular fractures + Failed osseointegration + Bony defects + Periapical implant lesion (Misch and Wang,2008)CLASSIFICATION (Carranza)| * Surgical complications * Biologic complications * Technical or mechanical complications * Esthetic and phonetic complications+ Hemorrhage and hematoma + Neurosensory disturbances * Damage to adjacent teeth Surgical complications * Inflammation * Dehiscence and recession Biologic + Periimplantitis and bone loss complications| * Implant loss or failure+ Screw loosening and fracture + Implant fracture + Fracture of restorative materials Technical complications + Esthetic complications + Phonetic complications phonetic omplication| Bleeding | + Common accident as a consequence of local-anatomical or systemic causes. ff jf Causes of bleeding: \ } \ 4 lesions in any sublingual, lingual, périmandibular, 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.* More prone patients fall in the following category: Group 2 of medical-systemic risk: O Irradiated patients (radiotherapy), O Patients with coagulation disorders (anticoagulated patients or those with haemostatic disorders) O Severe smokers (Buser et al., 2000)* Group I includes high risk patients: O Patients with serious systemic diseases (rheumatoid arthritis, osteomalacia, imperfect, osteogenesis), QO Immunodepressed (HIV, immunosupresory treatments), Q Drug addicts (alcohol, etc.), QO Unreliable patients (mental or psychological disorders).* 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): OFnternational Normalized Ratio (INR) are > 4, and OAdequate hemostatic measures are followed and, QUse atraumatic surgery techniques;Treatment: local intraoperative or postoperative measures Local hemostasis (suture, compression, the use of hemostatic microfibrilar colla uzes, oxidized cellulose, reabsorbable fibrin, or mouth rinsing with 48% of tranexamic acid* Swelling - more noticeable 24 hours after performing surgery * Causes: OWide flaps, OBone regenerating techniques, and Osurgery time+ 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.Careful management of tissues Non-steroid anti- inflammatory drugs corticosteroidsmorrhage/ Ecchymosis | + Severe bleeding and th ion 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 (710 mm).Ecchymosis are the result of an intermental surgery procedure.Aschematic representation of the arterial anatomy in the floor of the mouth (Kalpidis & Setayesh, 2004). a, at see Sublingual region ‘Sublingual artery Facia! artery Submandibular/mental region w* Signs or symptoms of life threatening hemorrhage include; Swelling and elevation of floor of the mouth O Increase in tongue size QO Difficulty in swallowing or speech O Pulsating or profuse bleeding from the floor of the mouth or the osteotomy siteTreatment of a hemorrhage at an implant osteotomy site (Park & Wang, 2005) Telecel Posterior mandible Mylohyoid Middle lingual of Submental mandible Anterior lingual of Terminal branch of mandible sublingual or submental Invading the mandibular Inferior alveolar artery canal 4 ecu) aad plant osteotomy Finger pressure at the site Surgical ligation of facial and lingual arteries Compression, vasoconstriction, cauterization, or ligation Bone graft* 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./Em physema | + 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 4 (Liebenberg & Crawford, 1997)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)[SO Maan i he i[ Causes | + INDIRECT : Postsurgical intra-alveolar edema a temporary pressure inc mandibular canal ematomas- produce ially inside the + DIRECT Compression, stretch, cut, overheating, and accidental puncture (Annibali et al., 2009). 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).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).SEDDON CLASSIFICATION * 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.+ SENSORY TESTING Sharp needle test( tingle or painful) Mapping area of altered feeling Shortest test between indentation Blunt cotton swab Temperatures test( test( tingle or Pulp testing teeth cold, painfulor none) warmth)optionalommendations to avoid nerve inj g implant placement (Worthingtor . a 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.Treatment (Misch & Resnik, 2010), * Too much proximity betweenthe 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 recover * Oral administration (high doses)- within one week of injury- prevention of neuroma formation- Remove offending element + Corticosteroids Recovery on1 to4 weeks NEUROPRAXIA + Remove offending element Corticosteroids + Recovery on 1 to 3 months + Complete anesthesia for more than 3 months * May have triggering signs or increase in sensation to sharp stimuli NEUROTMESIS* 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.iration and swallowin instruments Images of a screw driver in the digestive tract. (b) Screw driver into pulmonary tissue.+ 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 witha proper medical follow-up required to locate.aeence and exposure material or barrier memk + 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 ina diabetic patient with oral candidiasisContributing factors of dehiscence and exposure of the graft material or barrier membrane + 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)* Treatment Small No surgical correction dehiscence- Large + Resuturing dehiscence Free connective tissue grafts - - allows better esthetical results , maintenance of periimplant health (Speroni et al., 2010; Stimmelmayr et al., 2010).* Dehiscences may be prevented : 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.SCHNETDERTAN MEMBRANE PERFORATION + 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.c ; a : Schneiderian membrane perforation occurs in 10% to 60% of all procedures- aa \ Anatomical variations suchas 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.Management: Small tears (<5 to 8 mm) + folding the membrane up against itself as the membrane is elevated + do not lend themselves to closure by infolding + Repaired with collagen or a fibrin adhesive's of the implant or gr srials into the maxillary Causes: 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)Management: Immediately retrieved surgically via an intraoral approach or endoscopically via the transnasal route to avoid inflammatory complications Prevention: a bone reconstruction procedure of the maxilla should be performed.sition or angulation implant + The definition of a'malpositioned implant’ is an implant placed in a position that created restorative and biomechanical challenges for an optimal result. i Causes : \ / af he al ‘ most common - deficiency of thé osseous housing around the proposed implant site. Bone resorption : osseous remodeling following tooth loss, osteoporosis, etc.* Treatment: Use of repositioning system. Improves esthetic effects, the biomechanical behavior of the implantPrecautions: + 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 30°) or" * avoid anatomical structures (mental nerve, maxillary sinus).Improper implant ation/Implant displacem (a) Implant installed . (b) Control CT Scan after displacement and before second stage surgery. (c) Change of position.* Causes: There is an absence or loss of osseointegration and, Loss of stability Treatment: Tf 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. Precautions: Accurate surgical technique - using osteotomes to prepare the implant beds or adrill with a smaller diameter to that of the fixture, or using implants with a conical compressive form.| Injury to adjacent teeth” * This problem arises more frequently with single implants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),Precautions: + 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Mandibular | fracture Infrequent complication Perforation of the lingual cortical during drilling.* Associated with atrophic mandibles * Central area of the mandible has a greater risk for this complication * Treatment: Reduction and stabilization of the fracture with titanium miniplates or resorbable miniplates. Splinting implants to reduce and immobilize the fracture * Precautions: Thin mandibular alveolar crests- increase width by performing bone grafts Accurate tomography imaging studyScrew loosening * Incidence- 6% Stress applied to prosthes Crown height Cantilever Height or depth of antirotational co Platform dimensions on which the abutment is seatedManagement and precautions: + Large diameter implants with large platform dimensions reduce the forces applied to the screw + Decreased preload force + Increase thread tighteningIMPLANT EXPOSURE * Can be associated with exudate and bone loss * Protocol for partial exposure tinassociated with exudate: O Complete exposure of the implant cover screw ORemoval of the healing cover O Flushing of the implant with chlorhexidine, insertion of a permucosal extension O Oral hygiene with soft toothbrush O Chlorhexidine application over the area twice each day* Implant exposure associated with minimal bone loss 0 PME inserted, tissue approximated QO Membrane can be used O Antibiotics and chlorhexidine dailyrinses * Implant exposure with exudate and bone loss 0) Uncovering of implant, removal of cover screw O Curetting of granulation tissue O Cleaning of implant surface-diamond bur/ air abrasive O Bone grafts and membrane[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,Management: Removal of the implant and its replacement by another one (a) Implant fractured in maxillary posterior region. (b) Implants retrieved. (e) Substitution for a wider diameter in the same surgeryPERIIMPLANT MUCOSITIS HYPERPLASTIC MUCOSITIS) Periim pla ntitis * 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.+ Peri-implant mucositis was defined as reversible inflammatory changes of the peri- implant soft tissues without any bone loss (Albrektsson & Isidor 1994) Ina systematic analysis, 2003 * Incidence of periimplmant mucositis- 8-44% * Incidence of periimplantitis- 1- 19%eta de me BEY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)| Features Radiological evidence for vertical destruction of the crestal bone Formation of a peri-implant pocket Saucer shaped defect Swelling of the peri-implant tissues and hyperplasia Bleeding and suppuration on probingDiagnosis | Clinical indices, peri-implant probing, bleeding on probing (BOP), * suppuration, * mobility, peri-implant radiography microbiology.DIAGNOSTIC DIFFERENCES BETWEEN PERIIMPLANTITIS AND PERIIMPLANT MUCOSITIS Clinical parameter Peri-implant mucositis Peri-implantitis Increased probing depth __| +/- + BoP + + Suppuration +/- + Mobility +/- Radiographic bone lossent of peri-implant int Jd from Mombelli & Lai No visible plaque, | No BOP Plaque, BOP Peri-implant pockets 3mm OHT and local debridementNo BOP, no visible plaque No loss of bone when compared to baseline, Peri-implant pockets >3mm. Plaque+/_ BOP OHT and local debridement Surgical resectionLoss of bone. when compared to baseline moderate OHI and local debridement Surgical resection Topical antiseptic treatment Local antibiotic delivery Systemic antibiotic delivery Topical antiseptic treatment Local/ systemic antibiotic _ delivery F en debridement _ oO OHT and local debridement Local/systemic antibiotic delivery Open debridement Explantationtive Interceptive Supportive y (CIST) modalities (Lang et al * A. Mechanical cleansing using rubber cups and polishing pasty, acrylic scalers for chipping off calculus. Effective oral hygiene practices. * B. Antiseptic therapy Rinses with 0.1% to 0.2% nn «€ digluconate for 3 to 4 weeks, * supplemented by irrigating locally with chlorhexidine (preferably 0.2% to 0.5%) ‘C. Antibiotic therapy: 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).D. Surgical approach: 1. REGENERATIVE SURGERY * 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. RESECTIVE SURGERY * Apical repositioning of the flap following osteoplasty around the defect.Esthetic complication + Depends on patient s esthetic expectations and patient related factors(bone quantity and quality). * Depends on individual perceptions and desires* Esthetic complications result from: 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* Management: Reconstructive procedures to develop a natural emergence profile of the implant crown Appropriate treatment planning and implementation| Phonetic complica * Implant prosthesis with a ~ Unusual palatal contours (Restricted or narrow palatal space) J Spaces under and around the superstructure of implant Mostly observed in severe atrophied maxilla Management: implant assisted maxillary- overdentureld axillary sinusiti * Maxillary sinusitis can occur OContamination of the maxillary sinus with oral or nasal pathogens or Ovia ostial obstruction caused by postoperative swelling of the maxillary mucosa, ONon-vital bony fragments floating freely in the maxillary sinus. UO Lack of asepsis during sinus augmentation* General guidelines for the prevention of transient and chronic maxillary sinusitis after maxillary sinus a ntation (Timmenga et al., 2001 Preoperative evaluation of sinus clearance-related factors Postsurgery: a nasal decongestant (xylomethazoline 0.05%) and topical corticosteroid (dexamethasone oe to prevent postsurgery obstruction of the ostium Perioperative antibiotic prophy axis (cephradine 1 g 3 times daily, starting 1 hour before surgery and continued for 48 hours after surgery)Failed osseointegrati * 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.Implant failure Mechanical overloading Previous failure Surface roughness Surface purity and sterility Fit discrepancies Intra-oral exposure time Premature loading Traumatic occlusion due to inadequate restorationsPau (er Rc la el) Cerra yt) Cerra cy Bone quantity/quality Adjacent cate AL eles clay Presence of natural teeth Periodontal status of natural teeth Tiny er-reidtelaMey Miele -tam eles Cry Peat uy alee meee 4Cet-]| procedure) in the ae ee Se) eee eT oeDe GER eaa ated) Veet cena Smoking etl Cl Predisposition to infection, e.g. age, obesity, steroid therapy, metabolic disease (diabetes) Romer Chemotherapy/radiotherapy eee ena fey aaSurgical technique/environment Surgical trauma Overheating (use of handpiece) Perioperative bacterial contamination, e.g. via saliva, perioral skin, arise ell eyed) oe ey efrel tn wee uel meee expired by patientConclusior n 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.