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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 13-19

Management of surgical complication during dental implant placement


1 Department of Periodontology, Pravara Rural Dental College and Hospital, Loni, Ahmednagar, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, Rishiraj Dental College and Hospital , Bhopal, State: Madhya Pradesh, India
3 Department of Periodontology, Saraswati Dhanwantari Dental College and Hospital, Parbhani, Maharashtra, India

Date of Submission16-Dec-2020
Date of Decision16-Jan-2021
Date of Acceptance19-Jan-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
Preeti Prakash Kale
404/Department of Periodontology, Pravara Rural Dental College and Hospital, Loni, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_65_20

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  Abstract 


Replacement of missing teeth with dental implant is now preferred treatment option for edentulous space. Treatment with dental implants has evolved much in recent times and has good success rates which have sometimes led to unfortunate outcomes during procedure or after procedure. The present review gives insight about complications of dental implants associated with surgical procedures and its management in brief.

Keywords: Dental implant, implant failure, surgical complications, treatment


How to cite this article:
Kale PP, Mani A, Anarthe R, Pendyala G, Thakkur P, Sekharamantri AV. Management of surgical complication during dental implant placement. J Head Neck Physicians Surg 2021;9:13-9

How to cite this URL:
Kale PP, Mani A, Anarthe R, Pendyala G, Thakkur P, Sekharamantri AV. Management of surgical complication during dental implant placement. J Head Neck Physicians Surg [serial online] 2021 [cited 2021 Dec 2];9:13-9. Available from: https://www.jhnps.org/text.asp?2021/9/1/13/319750




  Introduction Top


Tooth loss is a traumatic for patients, even devastating occurrence, and this has doubtless been true throughout human history. Hence, the awareness to replace loss dentition is exponentially increasing day by day.[1] An outstanding result achieved by the use of dental implants has changed the smiles of millions of people all over the world.[2] The pioneering work of Professor Branemark and Andre Schroder ushered a new era in dentistry, i.e., The Era of Implant Dentistry. Branemark's determined research in osseointegration enabled the surgically related and prosthodontic disciplines an exciting scope in the new world of dentistry and gave it a global stand.[3] Treatment with dental implants has evolved from earlier much old procedures to a mainstream clinical activity, however, its potential benefits and high success rates have led to procedures sometimes being incorrectly used with unfortunate outcomes. Implants have evolved from its use as a functional device to a device which is esthetically acceptable.[4] However, treatment is not always successful because implant is a foreign body. The focus of implant research is shifting from descriptions of clinical success to the identification of factors associated with its complications or failure.[5] The related factors for failures could be broadly understood under preoperative criteria (patient selection and systemic diseases), perioperative criteria (sterilization and proper surgical protocol), and postoperative criteria (healing and prosthetics) to etiology attributed to biological or microbiological reason. Other reasons of dental implant failures are biomechanical or biomaterial factors or implant surface treatment and characteristic-related issues.[6] A better understanding of the factors related to implant failure will provide data for the planning of future studies, facilitate clinical decision-making, and enhance dental implant success rate.[7] The present review gives insight about complications of dental implants associated with surgical procedures and its management in brief.

Various Surgical Complications That Can Be Caused During Implant Placement And Their Management Are Discussed Below[8]

Anatomy-related complications

Hemorrhage

Bleeding during surgery

Bleeding during surgery is expected and usually easily controlled. If a sizable vessel is incised or otherwise injured during surgery, the hemorrhage can be difficult to control. Smaller vessels will naturally constrict or retract to slow the hemorrhage. If bleeding continues, it may be necessary to apply pressure or to suture the hemorrhaging vessel. In summary, if hemorrhage occurs during implant osteotomy, treatment includes compression, finger pressure, application of vasoconstrictor at site, cautery, bone graft, bone cement, and ligation of arteries.[9]

Postoperative bleeding

Following surgical procedure, patients should be given proper postoperative instructions to minimize bleeding instances. If on any anticoagulants, they are advised to discontinue or reduce medication dose as per physician approval 7–10 days before surgery in order to avoid postoperative bleeding risk.[9]

Hematoma

Hematoma formation results due to submucosal or subdermal hemorrhage into connective tissue and soft-tissue spaces. Bruising and small hematomas typically resolve without special treatment or consequence. However, larger hematomas or those that occur in medically compromised individuals are susceptible to infection as a result of the noncirculating blood that sits in the space. Treatment for noticeably large hematoma includes prescription of antibiotics to patient.[9]

Neurosensory disturbances

Damage to nerve causes neurosensory disturbances which can be temporary or permanent. Neuropath results by either a drilling injury (cut, tear, or puncture of the nerve) or compression of nerve due to implant placement.

Inferior alveolar nerve

The mandibular canal may deviate from its normal course and location; therefore, any attempt to prepare an implant bed lateral to the mandibular canal is extremely risky. If an instrument or the implant actually contacts the nerve, the patient will normally experience a pain sensation even under anesthesia. If this occurs, the surgeon must immediately stop the procedure and take appropriate radiographs and ligate nerve as soon as possible.[10]

Lingual nerve

Greenstein suggested the way to avoid damage to the lingual nerve during the preparation of the implant bed is to place a broad elevator between the lingual cortical plate of the mandible and the mucoperiosteal flap. Damage to the lingual nerve leads to loss of sensitivity in the anterior two-thirds of the ipsilateral half of the tongue. If fibers of the chorda tympani are severed, the patient will also lose some primary sensations (sweet, sour, and salt).[10]

Damage to adjacent teeth

Problem occurs most often with single-tooth implants; it should be avoided by the use of special diagnostic procedures. If instrumentation while preparing ostectomy site is directed at or near the adjacent tooth of concerned edentulous site, it might result in injury to periodontal ligament, nerves and vessels of adjacent teeth. Depending on the extent of injury the tooth may require endodontic therapy or extraction. Damage to adjacent teeth should be entirely preventable by appreciation of the local anatomy or disorientation in the direction of drilling with respect to the location and direction of the tooth root. The risks of surgery may always be present, but the complications can be minimized with an understanding of the etiology.[11]

Radiographic analysis

The adequacy of the height and width of the inter-radicular bone is checked carefully using panoramic radiographs with stents, periapical films, and millimeter gauges in the potential implant site and on adjacent teeth or grids attached to films.

The distance between the implant surface and the periodontal ligament space of adjacent teeth should be at least 2 mm. During the surgical placement of the implant, no contact must be made with the periodontal ligament of the adjacent teeth. This is of particular importance at the coronal aspect of the implant because marginal osseous defects can result.

Study cast analysis

Study casts are used to evaluate the possible width (intercoronal distance) and length of the planned implant-borne crown. In comparison to the other intraoral factors, consideration must be given to the position and shape of the contralateral tooth. Functional and occlusal aspects can also be evaluated using mounted study casts.

Cortical plate perforation

The thickness of buccal cortical plate is not uniform, hence traumatic extraction of teeth can cause ridge deficiency defect. In such thin buccal plate, if implant fixtures are placed too labially, it may result in fenestration or dehiscence implant defect. If the axis of insertion for the implant is chosen improperly, perforation of the external cortical plate of bone often occurs in the sublingual fossa or in the vestibule of the maxilla. If the sublingual fossa is perforated, no implant should be placed in that site. Perforations into the maxillary vestibule (fenestrations) can be successfully managed using the guided bone regeneration (GBR) technique. Small perforations of the basal cortical plate during preparation of the implant bed in the interforaminal region of the mandible usually have no negative consequences in terms of implant success. However, if this occurs, implant shorter than planned should be placed. If primary stability is achieved, then immediate correction of such defects can be done by placing particulate bone grafts and membranes. Potential sites for plate perforation should not be indicated for flapless implant placement.[12],[13]

Sinus membrane complications

Placement of dental implants in the maxillary posterior region can present with challenge to dentist due to proximity of maxillary sinus. The maxillary sinus lift technique is an accepted procedure to augment vertical height in the severely resorbed posterior maxilla area to facilitate proper implant placement.[14] Various complications can occur if membrane is perforated at the time of surgery. Hence careful n precise planning and surgery execution is utmost important at such site to avoid such complications. If accidentally implant gets land up in maxillary sinus which is very rare occurrence, transantral endoscopy is reliable and minimally invasive treatment option available, but it requires having an endoscope or a referral to an oral or ENT surgeon.[15]

Treatment plan-related complications

Long-term success and patient satisfaction of dental implants depend on well-organized and thorough treatment plan and its precise execution.

Improper angulation

Angulation of implant should be determined according to the future prosthesis with the consideration of buccolingual, apico-coronal, and mesiodistal positions related to it. If implants are tried to be placed on available bone without prosthetically driven approach, it may result in poor esthetic outcome as well as long term biomechanical stability can be compromised. Surgical guide templates can be of help for control placement of implant in accurate angle if they are made and used correctly. Choi et al. studied the effects of dimensional factors of the surgical guides on implant placement and concluded that the length of the guide channel was the primary factor in reducing angle deviations in the mesiodistal and buccolingual direction.[16] Mandibular teeth are inclined by 109° in relation to maxillary opposing arch dentition, and hence, it is important to place dental implants in the same inclination.[17] The use of finger rest while drilling for implant osteotomy site results in an inclination of drill toward the hand that is steadied, hence this principle of using finger rest should be avoided during implant placement procedure. The development of angled abutments has been a rescue technique for these wrongly placed implants and allows for a more successful aesthetic outcome.

Improper implant location

All interocclusal, interdental, ridge heights and ridge widths confirm whether dental implants are indicated in the first place of missing teeth. Adjacent teeth should be at least 1.5 mm from the implant body and more than 3–4 mm between adjacent implants to prevent horizontal bone loss as well as to preserve aesthetics. The spatial orientation while placing implant fixture should be in line with the occlusal plane and centered according to the opposing arch occlusion to prevent crossbites or additional stresses on the prosthesis. For more than one implant to be placed, a diagnostic wax-up should be used to determine the correct implant locations.[18]

Lack of communication

An informed consent should be obtained which must include potential surgical risk and complication in a way understandable to patient. Common problems to address include but are not limited to postoperative infection, bleeding, swelling, facial discoloration, transient pain, paresthesia, neuralgia, fracture, joint pain, muscle spasm, tooth looseness and sensitivity, recession, speech change, trismus, and swallowing of foreign objects. If a complication occurs during the postoperative healing time, then it is recommended to give emergency contact information as well.[19]

Minimal space between implants

Most implant manufacturers recommend a space of 4–7 mm between the neighboring dental implants to allow sufficient biologic space to exist as to avoid the necrosis that could happen because of blood supply impairment. Furthermore, sufficient space between implants maintains a proper hygiene protocol. The minimum space between an implant and a neighboring natural tooth should not be <3 mm to avoid impairment of blood supply of the periodontal ligament. The minimum space between two adjacent implants should range from 3 to 5 mm depending on the type of bone. In general, there should be a space of 3 mm between implants and between teeth and implants.

Procedure-related complications

Overheating the bone

During drilling of osteotomy site if temperature or duration increases, necrosis of bone can occur causing detrimental effects for osseointegration. Ericsson and Albrektsson showed bone resorption occurred at 47°C when drilling was applied for more than 1 min. Dense cortical bone (e.g., type I bone quality) when compared with type III or IV soft cancellous bone can be overheated when preparing osteotomies as more pressure is needed to advance the drill apically in comparison to cancellous bone. To reduce frictional heat produced by high speed handpieces, an up-down motion technique of the bone preparation using drill, and copious irrigation can be used.[20] Misch recommends using external and/or internal irrigation, cool saline irrigation, intermittent pressure on the drills while preparing osteotomy site, pausing every 3–5 s, using new drills, and the use of an incremental drill sequence. Generating less heat by preparing implant sites at 2500 rpm may decrease osseous damage.[21]

Lack of primary stability

The most important prerequisite for a connective tissue-free, ankylotic anchoring of an implant (osseointegration) is its primary stability in the bone immediately after placement. Lack of primary stability is a surgical complication that has to be dealt at the time of implant surgery. An unstable implant (e.g., a “;spinner”) should be removed or an attempt to place a larger diameter should be completed. Nonfunctional unstable implant can often lead to fibrous encapsulation that causes implant failure. If primary stability cannot be achieved during the surgical procedure, single-stage implants should be removed immediately. If a two-stage system is being used and the fixture exhibits minor mobility it may be possible to achieve “secondary” stabilization by choosing a longer implant (if possible) and by lengthening the nonloaded healing time.[22]

Jaw fracture

In patients with osteomalacia or osteoporosis alveolar bone is brittle. Placement of dental implant in such brittle bone may subject it to splintering because of development of loading or frictional forces created while drilling and placement. This may occur especially when more number of implants are placed as bone becomes mechanically weakened due to osteoporotic disease process.[23] Various other reasons which can be attributed to mandibular fracture includes the placement of wrong implant dimension for example: placing 12–14 mm length implant in 10 mm site prepared. To avoid this, implant size and diameter should be checked before opening the package. If at all fracture of jaw occurs, management should include stabilization using the wiring of a modified prosthesis, lag screws, wires, and plates. If an implant lies in the line of fracture, osseointegration will still occur as long as there is no mobility or infection.[24]

When placing endosseous implants in the severely resorbed mandible several precautions must be taken to avoid fractures.

  1. The inferior border of the mandible should be engaged without perforation
  2. The shortest possible implants should be used and spaced so that there is a least 5 mm of bone between the implants and 2 mm of bone between the implant and the buccal and lingual plates
  3. When inserting the implants, excessive tightening must be avoided.


Ingestion and aspiration

Dental implant comprises small components; hence, it is important to emphasize extreme caution when handling these small components in oral cavity. Most instruments have a special tip to help ensure screws and abutments transfer directly from the surgical tray into the patient's mouth, but nevertheless, accidents happen. To prevent such accidents, gauze throat screens and floss ligatures on implant components are encouraged. If at all patient swallows or aspirates an dental implant component, then they should be referred to the hospital because acute obstruction of airway can be life threatening complication and prolonging the removal of foreign objects may make a bronchoscopy procedure technically more difficult. If the foreign object is aspirated by patient, it should be removed within 24 h. Chest radiographs are a diagnostic tool available to rule out ingestion or aspiration.[25]

Emphysema

Inadvertent insufflation propulsion of air into tissues under skin or mucous membrane may result in tissue emphysema. Air from a high-speed handpiece, an 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; it is a rare complication though it can lead to severe consequences. Such complications can be avoided using a sterile water jet handpiece with retrograde air insufflation when, besides an associated dental implantology surgical process, it is necessary to dry the surface (periodontal treatment, laser, shutting, and periapical surgery on an adjacent tooth). Treatment of emphysema consists of prescribing antibiotics and a mild analgesic to patients, close observation for signs and symptoms, saline rinses frequently , light massage of affected area, application of heat packs in the affected area and provide mental comfort to patients. The problem usually resolves in 3–10 days.[26]

Implant displacement

Insufficient primary stability may result in displacement of implant into maxillary sinus. Implant displacements occur sometimes after an implant placement because there is an absence or loss of osseointegration (low osseous density around it). Implant can be retrieved by opening the lateral wall of the maxillary sinus or by endoscopy via through a nasal window; a process that allows a considerable good access to the zone and a lower postoperative morbidity than when it is performed intraorally. Patients may suffer from a marked sinusitis. Another complication is that the implant intrusion inside the sphenoidal and ethmoidal sinuses can occur when it is not removed during its migration. Such complication can be prevented with an accurate use of surgical technique that would include 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. If this complication unfortunately occurs, it must be solved immediately and carefully in order to avoid any migration of this foreign body to a more harmful anatomical space and region.[27],[28]

Soft-tissue lesions

Various lesions can occur during implant placement procedure such as burn lesions on the labial mucosa resulting due to overheating of the hand piece head, tear in flap due to an excessive traction or as a consequence of an incorrect use of instruments or any abrupt movement by the patient or the surgeon during the intended procedure. These lesions can mostly be avoided through a careful management of tissues or by sedating the patient and thus prevent the occurrence of stress situations for both surgeon as well as patient.[29]

Impaired healing and infection because of improper flap design:

Improper flap design could lead to an early infection at the implant site which would jeopardize the implant status. The clinical signs of infection observed during the postoperative submerged period may lead to an increased risk of implant failure. Also, systemic conditions like diabetes mellitus, anemia, uremia, and jaundice play a role in wound healing impairment. Hunt (1990) studied the effect of flap design on healing and osseointegration of dental implants. He found that there is no single-flap design that seems optimal for implant surgery.

Atraumatic surgery minimizes the risk of postoperative infection and optimizes the healing process. Proper incision design maintains a proper blood supply. Broad-based surgical flaps with incisions as long as to allow enough mobilization and retraction for visualization should be given. When there is minimal amount of keratinized tissue, the incision should be placed buccal or labial to the alveolar crest, slightly into the unattached mucosa minimizing the possibility of compromising blood supply. Both vestibular and crestal incisions are advocated. Crestal incision is easier and faster to perform. Advantage of vestibular incision is that since the implant is not directly located under the incision, there is less chance of dehiscence and implant exposure. Flaps should be closed without tension and the surface epithelium should not contact the periosteum because this may result in delayed healing and opening of the incision.[29]

Contamination of the implant body before insertion

Implant should not be handled and contaminated as it may lead to alteration in surface chemistry or contamination of surface. The implant may be contaminated because of manufacturer errors, by the operator, from nontitanium instruments or by bacteria (oral cavity). An implant surface contaminated with bacteria possibly may be derived from plaque contamination while the implant is being inserted. Autoclaving a contaminated implant will bake the bacteria on to the implant surface so that when the implant is placed in the body, it becomes almost impossible for phagocytic cells to clean off this material. This may contribute to the failure of an implant because it prevents the close adaptation of bone. Dental implants can also be contaminated via metal transfer (the implant is grasped with a nontitanium instrument). All instruments that contact implants should be titanium tipped to avoid metal contamination. Another factor that contaminates the implant surface is glove powder which acts as a film over the implant body if contact occurs. The implant surface should be cleaned by a radiofrequency glow discharge unit or plasma cleaner. Clean and disinfect instruments and drills in an ultrasonic cleaner. Dry the instruments. Place in sterilization packets. Sterilize the instrument using a steam autoclave.

Placing the implant in immature bone-grafted sites

One of the most common causes of prosthetically related implant failure is believed to be the too rapid loading of the implant-supported prosthesis. The problem with implant placement in grafted bone site is timing, i.e., the implant is loaded before the surrounding bone matures from woven then into lamellar bone. Hence, the failure incidence is much higher because of the nature of woven bone. Woven bone is the fastest and first type of bone to form around the interface. This is partly mineralized and demonstrates an unorganized structure unable to withstand full-scale stresses on it. Conversely, lamellar bone is considered ideal for implant prosthetic. Placing an implant in immature grafted bone will not provide the implantologist with intimate implant-to-bone contact, which is essential for the implant to resist applied torque. Placing the implant in mature fresh bone, the maximum implant-to-bone contact will be obtained. The waiting period is mandatory for implant survival in cases of grafted bone sites (6–9 months). Overheating the bone and exerting too much pressure before the allotted time means that the woven bone would be loaded. This adversely affects implant survival.[30]

Placement of the implant in an infected socket or a pathologic lesion

Dental implants may fail because of:

  • Placement of the fixture into an infected socket (immediate implant placement)
  • An existing pathological lesion (e.g., cyst)
  • Migration of infection from a neighboring tooth via marrow space.


During the initial stage of osseointegration, the implant is particularly vulnerable to infection from an adjacent endodontic lesion. It was suggested that an implant does not have the ability to withstand any bacterial challenge during the first stage of osseointegration. It is also suggested that an endodontic lesion can travel through marrow spaces and contaminate an adjacent implant fixture. Such vulnerability could be explained by the absence of a periodontal ligament, and because after placement of an implant the interfacial bone takes time for osseointegration. Another situation that may lead to failure is the immediate placement of an implant into an infected socket because of the previous presence of an infected tooth (endodontically or periodontally). It was proposed that the placement of an implant into a socket with a chronic lesion does not necessarily result in failure if certain precautions are taken. Complete removal of the causative factor (the tooth) with careful and thorough debridement of the socket with antiseptic solution in addition to the use of antibiotics reduces or eliminate the chances of bacterial contamination so that the host cells deal with the residual infection if at all present. In addition, placing an implant in or near a cystic cavity does not necessarily subject the implant to immediate failure. Later, it may be jeopardized because of the expansion of the cyst. Mucous membrane disinfection prior to procedure, skin preparation, and isolation of the surgical field with sterile barrier draping can be accomplished to the level appropriate for the procedure intended. In conclusion, by the proper and careful examination of the patient and the intended implant sites, the surgeon can improve the success rate of dental implants by avoiding situations such as placement into infected sites.[30]


  Complications of Dental Implants Associated with Augmentation Procedure and its Management Top


GBR is a procedure that utilizes a barrier membrane to isolate an area for bone regeneration. The most common complication associated with GBR is premature exposure of the barrier membrane and necrosis of the overlying flap and lesions associated with periosteal releasing incision. Other complications associated with GBR procedures include soft-tissue infections, bone graft infection, failure to regenerate adequate bone volume, and mucogingival problems such as loss of keratinized tissue and decrease in the vestibule. Most of these complications can be attributed to insufficient soft-tissue healing after tooth extraction, inadequate flap design, movement of the membrane and/or graft caused by transmucosal loading and improper provisionalization, flap suturing under tension, poor surgical technique, contamination of the membrane or surgical site, compromise of the vascular supply and flap advancement for graft coverage that reduces the keratinized tissue, and vestibular depth. To avoid such complications, adequate healing of the soft tissue before performing a GBR procedure should be allowed. All possible sources of infection should be eliminated before surgery (i.e., periodontally, endodontically, or hopelessly involved teeth). Design the flap in such a way, it ensures adequate blood supply and flap closure. Adequate knowledge is required regarding oral anatomy and the prevention and treatment of complications associated with same.[31]


  Conclusion Top


Surgical complications are common during dental implant placement. It is better to be more precise, organized, and careful during surgical placement of dental implant. If at all complication occurs, they have to managed carefully.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
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