Medicine,SchoolofDentistry,UniversityofMichigan,AnnArbor,MI. - PDF document

Medicine,SchoolofDentistry,UniversityofMichigan,AnnArbor,MI. ProfessorandDirectorofGraduatePeriodontics,DepartmentofPeriodonticsandOralMedicine,SchoolofDentistry,UniversityofMichigan,AnnArbor,MI.ISSN1056-6163/08/01702-159ImplantDentistryVolume17¥Number2Copyright©2008byLippincottWilliams&WilkinsDOI:10.1097/ID.0b013e3181752f61Implantsurgerycomplicationsarefrequentoccurrencesindentalpracticeandknowledgeinthemanagementofthesecasesisessential.Theaimofthisreviewwastohighlightthechallengesoftreatmentplan-related,anatomy-related,andprocedure-relatedsurgicalcomplicationsaswellastodiscusstheetiology,managementandtreatmentop-tionstoachieveasatisfactorytreatmentoutcome.(ImplantDent2008;17:159Ð168)KeyWords:dentalimplants,implant Bleeding Cortical plate perforation adjacent teeth Other Iatrogenic Human error Procedure Related Lack of primary stability Mechanical complications Mandibular fracture medicalmalpracticepaymentreportswereagainstdentistsin2002.13Inden-tistry,themaincausesforlawsuitsareactualbodyinjury(eg,lossofsensa-tion,oroantralfistula,life-threateningbleeding)andmajordisappointment.14Thiscouldbeavoidedifapatientunderstandsthefundamentalsofthesurgicalprocedureandwhatistobeanticipated.AvaluabletoolusedtocommunicatebetweensurgeonsÕand alsoreportedasimilarincidencerateof6.5%foralteredsensationat1 KalpidisandKonstantinidis29re-portedacaseinvolvingaperforationofthelingualcorticalplateduringanimplantosteotomypreparationofthefirstmandibularpremolarposition.Acriticalhemorrhageandmultiplehe-matomasimmediatelyoccurredafterperforationwhichwasverifiedbyaCTscan.Risksites30asdescribedaboveintheposteriormandibleincludethesublingualfossaandlingualcortex.Arupturedarteryintheareawithin30minutes,cancauseabloodlossrateof14mL/min31andif%500mLofbloodlossoccurs,hypotensioncanresult.32Life-threateningairwayobstructionisaseriousthreatandearlytreatmentisessential.Treatmentinvolveshavingthepatientstickouttheirtonguetocompressthebloodvesselsagainstthebodyofthemandible.Placingpres-surewithgauzeinthesublingualareadoesnotworkasonewouldintuitivelythink.Extraoralpressuretothesub-mentalorsubmandibulararteriesfor20minutesagainstthebodyofthemandiblehelps.33Theposteriorsuperioralveolarandinfraorbitalarteriesarelocatedapproximately19mmabovethemax-illaryalveolarridge,34andtheanasto-mosesofthesearteriescanposeariskduringsinusliftproceduresbylateralwindowpreparation.Bonewax,pres-sure,crushing,andelectrocauterycanalleviatehemorrhage.Insummary,hemorrhagetreatmentsatimplantos-teotomysitesincludecompression,fingerpressure,vasoconstriction,cau-tery,bonegraft,bonecement,andli-gationofarteries.33CorticalPlatePerforationThebuccalcorticalplatevariesinthicknessthroughoutthemouthandtraumaticdentalextractionscancausemarkedlythinplatesorconcavities,aswellasoverallridgewidthdeficiency.35Whenpreparingosteotomysitesorplacingimplantfixturesinareaswithminimallabialplatethickness,oriftheimplantisplacedtoobuccally,afenestrationordehiscenceimplantde-fectisacommonfinding.Afenestra-tionleavesintactbonecoronallywiththeexposedthreadsattheapicalpor-tionofthecrest,whereasadehiscencedefecthasthecoronalportionoftheimplantexposed.TintietalclassifiedthesedefectsasClassIiftheimplantwaswithintheenvelopeofboneandClassIIifitwasleftstayingoutsidetheenvelope.Immediatecor-rectionwithparticulatebonegraftingwithorwithoutamembraneduringthetimeofimplantplacement,canbedoneaslongasprimarystabilityhasbeenachieved.ÒFlaplessÓimplantsur-geriesshouldbeavoidedinareasofpotentialperforationofthebuccalorlingualbone.SinusMembraneComplicationsInthemaxillaryposterior,theproximityofthesinuses37,38cancreateaproblemfordentalimplantsifthereisminimalresidualcrestalbone($5mm)forstability.Themaxillarysinuslifttechniqueisanacceptedproce-dure,demonstratedbyTatum,39toaugmentverticalheightintheseverelyresorbedposteriormaxillaareatofa-cilitateproperimplantplacement.Si-nuscomplicationsoftenoccurredwhenthemembraneisperforatedattimeofsurgery.Ardekianetal40foundmaxillarysinusmembraneperfora-tionsweremorecommoninareaswithminimalamount($5mm)ofresidualalveolarbonebutthisdidnotaffecttheoverallimplantsuccessrate.Nostatisticaldifferenceswerefoundbe-tweentheperforationgroupcomparedwiththeintactmembranegroup.Incontrast,Proussaefsetal41foundim-plantsurvivalatsecond-stagesurgerywassuperiorforthenonperforatedsites(100%)comparedwithperfo-ratedsites(69.6%).Bonedensityaftergraftingshouldbeassessed,regardlesswhetherornotaperforationoccurs,becausepoorbonequalityoftenleadtoahigherimplantfailurerate.34Whathappensifanimplantpro-trudesintothemaxillarysinuscavity(Fig.5)?Jungetal42reportedtheriskofmaxillarysinuscomplicationsinimplantswhichpenetratedtheboneandmucousmembraneofthesinusfloorat2,4,and8mmextensions.After6months,radiographicandhis-tologicexaminationsdidnotshowanysignsofpathologicfindingsinthemaxillarysinusofthe8dogs.Despitetheconvincingresults,thequestionre-mainswhether6monthsisalongenoughfollow-upperiod.Hence,ithasbeensuggestedthatsimultaneousimplantplacementduringsinusliftproceduresisnotconsideredacontra-indicationorlesspredictableproce-dure.Nonetheless,carefulplanningandprecisesurgeryexecutionarees-sentialtoavoidanypotentialsinuscomplications.Lastly,losinganimplantintothemaxillarysinusisarelativelyuncom-monsurgicalcomplication.However,incaseswithlessthan5mmofbone,masticationcancausetheimplantstomoveduringthegraftmaturationtimeframe.43Transantralendoscopicsurgeryisareliable,minimallyinva-sivemethodforretrievingdisplacedobjectsfromthemaxillaryantrumwithminimalcomplications,44,45butitdoesrequirehavinganendoscopeorareferraltoanENTororalsurgeon.DevitalizationofAdjacentTeethAdjacentteethatimplantrecipientsitesshouldbeevaluatedbeforeimplantplacement.Pulpalandperiradicularconditionssuchassmallperiapicalra-diolucencies,rootresorptionandlargerestorationsin/nearthevitalpulpareoftenmisdiagnosed.Numerouscasereports33,46,47describeimplantpathosiscausedbydormantendodonticprob-lemsofadjacentteeththatflareupafterimplantsurgery.48Therefore,itisFig.5. Otherreasonsformandibularfracturemayincludeusingthewrongimplant(eg,10mmsitepreparationwithintentofplacinga12or14mmimplant).Checkingtheim-plantsize/diameterbeforeopeningthepackageisimportant.Afractureofthemandibleshouldberestoredtomaintainformandfunc-tion.Managementshouldincludestabilizationwithanattempttoalsosimultaneouslyeliminateatrophyifindicated.AretrospectivestudybyEyrichetal Twominiplatesoracombinationwithmicroplatescanobtainstablefixationinseverelyatro-phicfracturedmandiblesandisalessinvasivetreatmentoption.64IngestionandAspirationForthesakeofcompleteness,itshouldbementionedthatextremecau-tionshouldbeemphasizedwhenhan-dlingsmallimplantcomponentsintheoralcavity.MostinstrumentshaveaspecialtiptohelpensurescrewsandabutmentstransferdirectlyfromthesurgicaltrayintothepatientÕsmouth,butnevertheless,accidentshappen.Unfortunately,componentswindinguponthefloorordownapatientÕsthroatcanbeembarrassingandexpen-sivemishaps,nottomentionseriousimplicationscouldoccurifaspirationtakesplace.Forthesereasons,preven-tativemeasuressuchasgauzethroatscreensandflossligaturesonimplantpiecesareencouraged.Tiwanaetal,65foundovera10yearretrospectiveinstitutionalstudy,only36casesofingestionwerereportedandamazinglyonlyonecaseofaspiration.Fixedprosthodontictherapyreportedhavingthemostincidencesofingestion.Inparticular,cementedsingle-toothcastorprefabricatedrestorationshadahigherlikelihoodofaspiration.Ifapatientswallowsoraspiratesanimplantcomponent,theyshouldbereferredtothehospitalbecauseacuteobstructioncanbelifethreateningandprolongingtheremovaloffor-eignobjectsmaymakeabronchos-copytechnicallymoredifficult.66Iftheforeignobjectisaspirateditshouldberemovedwithin24hours.Chestradiographsareadiagnostictoolavailabletoruleoutingestionoraspiration.OtherAstudydonebytheDentalIm-plantClinicalResearchGroup67foundthatinexperiencedsurgeons($50im-plants)weretwiceaslikelytohaveimplantfailurescomparedwithmoreexperiencedsurgeons.Suchastatisticisagoodreminderinrealizingthatsomeofourliteratureisbasedontheworkofgraduatestudentswhostartoutasama-teurimplantsurgeonshencethedatacannotbegeneralized.Therealizationalsoexiststhatmanygeneraldentistsstartingtoplaceimplantsmayhavemorefailuresandcomplicationscom-paredwithexperiencedspecialists.CONCLUSIONSurgicalimplantcomplicationsarenotuncommonandshouldbead-dressedimmediately.Causalitymaybeiatrogenic,duetopoortreatmenttechniques,orlackofcommunicationbetweendentaldisciplines.TimeshouldbespentintheimplantÒplan-ningÓstages,suchastracingpreoper-ativeradiographs,measuringmodels,takingCTscansandmakingpropersurgicalguides.Basicanatomymust Bone grafting, membranes, sutures, back-up implant, shorter implants, root canal therapy Abort treatment Lack of primary stability Over-prepped osteotomy Large dehiscence or fenestration Nerve trauma Fracture of the mandible Short distance (mm from adjacent tooth) Auxillary Refer when indicated Accomplish treatment Post operative instructions Post operative medications Narcotic, antibiotic, sedative, anti-inflammatory Fig.6. 4.WongN,Huffer-CharchutH,SarmentD.Computer-aideddesign/computer-aidedmanufacturingsurgicalguidanceforplace-mentofdentalimplants:Casereport.ImplantDent.2007;16:123-130.5.JaberoM,SarmentDP.Advancedsurgicalguidancetechnology:Areview.ImplantDent.2006:15;135-142.6.WilliamsPL,WarwickR.36thed.Edinburgh:ChurchillLivingstone;1980:1281-1287.7.TanakaT,ShawP.Anatomyforim-plantdentistry:Mandible.QuintessenceDentImplantol.1995;2:10-20.8.ChoquetV,HermansM,MalevezC,etal.Clinicalandradiographicevaluationofthepapillaleveladjacenttosingle-toothdentalimplants.Aretrospectivestudyinthemaxillaryanteriorregion.JPeriodontol.2001;72:1364-1371.9.TarnowDP,ChoSC,WallaceSS.Theeffectofinter-implantdistanceontheheightofinter-implantbone. hashinayim.2003;20:44-50.25.KrautRA,ChahalO.Managementofpatientswithtrigeminalnerveinjuriesaf-termandibularimplantplacement.JADA. 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GERMAN/DEUTSCHAUTOR(EN): �=-4:/+'6)(4$($:;"&)"34/4+56%++'6)(4$(7++;4/-!(.4(5+'6)(4-$(7+5.TURKISH/TU¬RKCüEYAZARLAR:DisHekimiKellyMisch,DisHekimiHom-LayWang.Yazõsümaicüin:Hom-LayWang.,DDS.,MSD,PhD,Dept.ofPeriodonticsandOralMedicine,UniversityofMich-igan,SchoolofDentistry,1101N.University,AnnArbor,MI48109-1078ABD.Telefon:734-763-3383,Faks:734-936-0374,eposta:homlay@umich.eduOralmplantolojideProfilaksiAmacõylaAntibiyotikRe-jimi:NedenlerveProtokol…ZET:Oralimplantolojideantimikrobiyalilakullanõmõ,cerrahiyaradakienfeksiyonlarõazaltõr.Antimikrobiyalpro-filaksi,tŸmSõnõf2(temiz-kontamine)cerrahiprosedŸrleriiinendikeolup,bunlaradentalimplantõnbakteriyelkon-taminasyonusõrasõndayeterlidŸzeydekanbulunancerrahi