local complications in dental implants surgery
Post on 07-May-2015
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PREVENTION AND TREATMENT
DISTINCTION BETWEEN
ACCIDENTS - events that occur during surgery
COMPLICATIONS – all the conditions that appear postoperatively
~early stage complications appear in the immediate postoperative period & interfere with healing
~late stage: during the process of osseointegration.
EARLY STAGE COMPLICATIONS
INVOLVE : maxillary sinus or mandibular bone soft tissues & nerve trunks adjacent to the implant site.•CAUSES - excessively traumatic surgical approach -bone overheating during osteotomy -bacterial contamination of the host site.
DURING FIRST FEW POST-OPERATIVE DAYS -edema, exudate & pain.CAUSES: bacterial contamination during surgery ~directly or indirectly.PREVENTION- of the infection mainly depends on asepsis -sterile working area -disinfection of perioral skin with povidone iodine & alcohol -disinfection of oral mucosa with 0.2% Chx(studies have shown reduction in infections 4.1% test group 8.7% control group by Chx use)
EDEMA
ACCUMULATION OF EXCESS PLASMA FLUID (transudate) in the interstitial spaces (at least 10% increase)
Edema is related to extent of surgical trauma & duration of surgery .
Negatively affects healing, and causes discomfort during food intake & oral hygiene maintenance.
Prevention - atraumatic surgical technique - minimal tissue damage - ice packs & administration of
corticosteroids
ECCHYMOSES & HAEMATOMAS
NOT COMMON CAUSES - long & complex procedures - lack of patient compliance with the instructions given for the postoperative period
-vessel fragility(esp. in elderly pt.) -failure to discontinue anti-platelet therapy before surgery•MANAGEMENT- topical skin application of heparin containing medications.
EMPHYSEMA
Rare complication; from a sudden rise of the intra-oral pressure. ie when the pt. sneezes
CLINICALLY - swelling of half of face; extending at times to neck & thorax - crackling sound heard upon palpation• MANAGEMENT-massages & compression with ice packs .• PREVENTION- avoid use of high velocity instruments to prepare the bone bed or irrigation of the wound with hydrogen peroxide.
BLEEDING
Causes - failure to stabilize flap -tearing of soft tissues -masticatory trauma -early temporization and inappropriately modified temporary prosthesis.•MANAGEMENT- compression & tamponade with surgical gauzes soaked in tranexamic acid.
- if bleeding persists, re-elevate flap, remove clotted blood & place new sutures to immobilize the soft tissue and promote clot formn. And stabilization.
FLAP DEHISCENCE
Is the opening of the surgical wound edges exposing implant head &/or surrounding bone tissue.
Causes - thin mucosa - failure to ensure passive re-approximation &
closure of flap margins (thus unable to counter intramural mechanical stress- due to muscle and bone interaction)
- insufficient or extensive tension on the suture(leads to soft tissue necrosis) - functional movements, mastication,
phonation or deglutition.
Causes contd..
- Previous radiation therapy which affects flap vascularity- Incomplete tightening of the cover screw (due to presence of blood residues)- Bone debris trapped under the periosteum- Cigarette smoking & local effects of nicotine (cytotoxic & vasoactive substances) & systemic (altered granulocytes & T-cells), impaired production of antibodies & vasomotor substances.
If small If small If large If large
no surgical correction, as the granulation tissue which forms would promote healing .
granulation tissue formation process lasting >2 wks may require refreshing the epithelial wound margins
removing the sutures & re-suturing.
Treatment - based on extent of exposure
Prevention of Dehiscence :
Careful preoperative assessment of the soft tissues, to measure the amount of keratinized mucosa present & planning of augmentation procedures as appropriate.1.Minimally invasive flap elevation & reflection with careful removal of any bone debris 2.Proper suturing3.Sensible temporization with appropriate modifications; rebasing & relining4.Delaying the use of removable dentures until 2 wks after surgery
SENSORY DISORDERS
Results from injuries to the nerve trunk May lead to hyperesthesia, hypoesthesia or
anesthesia. SYMPTOMS- numbness, tingling, hot & cold,
pain, swelling, hardening, burning, loss of saliva, prickling, tickle, electrical shock sensation, itch.
lower jaw more affected - lower lip 54-64%, chin 46-58%, gum tissues 32-45%, tongue 11-16%
Reversible Reversible Permanent Permanent
Compression by edema or hematomas
Excessive stretching (>8% elastic limit) of the mental nerve during flap reflection
Injuries to inferior alveolar nerve or mental nerve during osteotomy leads to permanent sensory alteration along with hyperalgesia.
Nature of damage
Early stage Early stage Late stage Late stage
Immediately after injury occurs
Assessment of symptoms
X-rays performed No radiographic
changes - wait & see attitude is advisable since the symptoms may result from
"stunned nerve syndrome" (neuropraxia)
When symptoms persist or worsen
Clinical investigations- mechanoreceptive, thermal, electric,nociceptive & chemical tests repeated monthly, gustatory sensitivity tests
Lab tests -blink reflex test, Computerised tomography, nuclear magnetic resonance
Diagnosis
Immediate postoperative periodImmediate postoperative period
First month after surgeryFirst month after surgery
Combination drug therapies with NSAIDs, cortisones, proteolytic enzymes, antibiotics & vit C & E - to reduce nerve trunk compression by edema or hematomas
To promote nerve regeneration - vit C & D, vasodilators & ozone therapy (to prevent ischemia), magneto therapy, low level laser therapy & transcutaneous electric nerve stimulation (TENS)
nerve reconstruction- 1)neurorrhaphy 2) grafting 3) tubulization
Treatment
Late: MAXILLARY SINUSITIS
As a result of bacterial contamination during surgery or healing for wound dehiscence or implant placement into sinus
ACUTE CASES : pain, edema , swelling, reddened soft tissues
CHRONIC CASES: massive proliferation of mucosa, thickening of membrane, polypoid masses filling the sinus,decrease air in sinus and antral content become radiopaque
Treatment
Systemic therapy- antibiotics, Chx mouthwashes, saline irrigation through nasal orifice & use of nasal decongestants
If infection worsens or a dislodged implant in sinus - radical revision surgery of sinus & the antral mucosa completely removed.
Prevention - screening patients prior to surgery for sinustis or predisposing factors
- prophylactic antibiotic therapy -asepsis
MANDIBULAR FRACTURES
Rare - occur during osseointegration, after restoration or as a result of trauma.
Cause unknown; but fracture lines consistently pass through implant sites , as stresses converge & loss of bone density occurs .
Clinical signs : pain, swelling, impaired function & fistulae in fracture area
Diagnosis - clinical evaluation: movement of fractured segment, crackling sounds, signs of infection
-radiograph: radiolucent area through implant site
Treatment
Aligned fractures : antibiotic therapy +soft diet Mal-alinged fractures : reduction & immobilization
Prevention• Bone should be 7mm in height & 6mm in
width , if not ridge expansion or augmentation
• Avoid preparation of multiple bone beds• 5mm of hard tissue left between two sites• Avoid overscrewing of implant• Keep mandible at rest during healing
FAILED OSSEOINTEGRATION
Diagnosed at phase II surgery or restoration Results in loss of implant Causes: reduced healing, occlusal loading during
osseointegration, bone overheating(>47°C for 1min; radiographically visible after 2-4 wks)
Diagnosis: loosened implant & muffled sound upon percussion
Radiographically, radiolucent margin around implant
Treatment : removal of implant & debridement of the area
BONE DEFECTS
Can be horizontal or verticalCAUSES: 1. Direct trauma to bone or insult to
periosteum (reduced vascularity) 2. Decreased bone density 3. Implant placement into fresh extraction site 4. Wrong inclination of the implant 5. Excessive torque during insertion 6. Thin alveolar crest 7. Wound dehiscence during healing 8. Perforation of mucoperiosteum 9. Postoperative infection
Diagnosis
Patients are asymptomatic, thus radiographic examination of crestal bone-implant interface.
Treatment: •vertical defect a) <2mm -horizontal osteotomy b) >2mm- autologous bone graft ; if bone loss >25% grafting + membrane
uncovering of implant postponed by 2- 4months
Treatment contd..
Horizontal defect a) small- apical repositioning of soft tissues b) large - autologous graft + membraneuncovering of implants postponed by 3-4mnths prevention •Plan treatment according to quality & quantity of bone present
PERIAPICAL IMPLANT LESION
Is a pathological area of osteolysis at the apex of an osseo-integrated implant Cause: 1) accidental sectioning of the neurovascular bundle 2) pre-existing bone infection 3) foreign bodies or root fragments 4) sinus infections 5) contamination of implant 6) compression of bone debris , causing ischemia-necrosis & bone sequestration.
MAIN CAUSES:CONTAMINATION OF RECENTLY INSERTED IMPLANTS BY PATHOGENIC MICROFLORA. IT MAY BE FAVORED BY PRESENCE OF NECROTIC ANT TRAUMATIZED BONY TISSUE AND/OR IMPAIRED HOST MECHANISM.
C/F – EDEMA , SWELLING , PURULENT EXUDATE, PAIN ON PALPATION OR FISTULAE.RADIOGRAPHIC FEATURE- MARKED BONE RESORPTION.
TREATMENT: IF BONE IS NOT INVOLVED, A FLAP IS ELEVATED TO DRAIN THE ABSCESS AND REMOVE GRANULATION TISSUE.FOLLOWED BY SALINE IRRI.& ADM-LOCAL ANTIBIOTICS IF BONE RESORPTION+, A GUIDED BONE REGENERATION PROTOCOL WILL BE FOLLOWED.
POSTOP- ANTIBIOTIC THERAPY: IN BOTH THE ABOVE CASESAMOX+ CLAVULANIC ACID- 2G+METRON- 750MG & .12% CHX FOR ORAL HYGIENE.
Infection
Conclusions:
Local complications arising during the implant surgery are the main determinants of the outcome of the entire rehabilitation program.
Hence, the prevention of the complications sh be our main objective.
Therefore, careful clinical and radiographic examination, accurate treatment planning, proper planning of procedures, use of proper surgical techniques, appropriate instruments and correct management of healing and osseointegration are all the important aspects in preventing the complications.
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