Peri-operative complicationsOccurrence, prevention and

handling

Dr. Luc Vrielinck

Peri-operative complicationsOccurrence, prevention and handling

• Definition:Complications occurring during surgery or until soft tissue healing

• The presentation is mainly focused on standard implant placements without soft and hard tissue augmentation procedures

Peri-operative complicationsOccurrence, prevention and handling

• Topics– Bleeding– Swelling– Root Injury– Nerve injury– Displacement of implant– Infection– Pain– Fracture

Peri-operative complicationsOccurrence, prevention and handling

• Topics– Bleeding– Swelling– Root injury– Nerve injury– Displacement of implant– Infection– Pain– Fracture

Bleeding - occurrence

• Severe haemorrhage– Rare– Potentially life-threatening

Bleeding - occurrence

Source Patient Age Sex Implant Site Time until

bleeding Access Intubation

Time spent in Intensive

care

Duration of

Hospital Stay

Givol et al., 2000 63 F 33 0 Intraoral Emergency

tracheotomy 0 11

Panula & Oikarinen,

199942 M 43 0,5 Intraoral Yes 2 Ca. 7

Mordenfeld et al., 1997 69 F 43 0 Extraoral Yes 1 4

Bruggenkate et al., 1993

58

42

F

F

33 or 43

44

6

0

Intraoral

Intraoral

Yes

No

4

1

8

1

Laboda, 1990 67 M 33 0 Extraoral Yes 2 6

Mason et al., 1990 54 F 43 Etwa 4 Intraoral Yes 2 2

Krenkel et al., 1986 59 F 33 4 Intraoral Yes 0 6

Darriba et al.,1997 72 M 34, 32, 42, 44 0 Intraoral Emergency

tracheotomy >1 14

Bleeding - occurrence

Source Patient Age Sex Implant Site Time until

bleeding Access Intubation

Time spent in Intensive

care

Duration of

Hospital Stay

Givol et al., 2000 63 F 33 0 Intraoral Emergency

tracheotomy 0 11

Panula & Oikarinen,

199942 M 43 0,5 Intraoral Yes 2 Ca. 7

Mordenfeld et al., 1997 69 F 43 0 Extraoral Yes 1 4

Bruggenkate et al., 1993

58

42

F

F

33 or 43

44

6

0

Intraoral

Intraoral

Yes

No

4

1

8

1

Laboda, 1990 67 M 33 0 Extraoral Yes 2 6

Mason et al., 1990 54 F 43 Etwa 4 Intraoral Yes 2 2

Krenkel et al., 1986 59 F 33 4 Intraoral Yes 0 6

Darriba et al.,1997 72 M 34, 32, 42, 44 0 Intraoral Emergency

tracheotomy >1 14

Bleeding - occurrence

• Severe haemorrhage in the floor of the mouth– Rare– Potentially life-threatening– Mainly a problem in the anterior mandible

• Sublingual artery• Submental artery

• Systematic pre-operative evaluation– Medical history– Clinical examination– Radiographic imaging

Bleeding - prevention

Goal: Identify risk patients

We don’t like surprises

• Systematic pre-operative evaluation– Medical history– Clinical examination– Radiographic imaging

Bleeding - prevention

Bleeding - prevention

• Medical history– Systemic diseases

• Coagulopathy• Thrombocytopathy/-penia• Hyperfibrinolysis• Vessel wall defects• Connective tissue disorders• Liver disease• Alcoholism Iif at all in doubt –

contact the patients’ physician

Bleeding - prevention

• Medical history– Systemic diseases– Medication

• Antithrombotic medication > 95%

Main rule:

Don’t discontinue antitrombotic treatment:The risk of a severe bleeding complication is most often much lower than the risk of a thrombo-embolic event if the medication is stopped

Bleeding - prevention

• Medical history– Systemic diseases– Medication

• Antithrombotic medication > 95%

Be aware of the many interactions especially between

anticoagulants (Vit K antagonists) and antibiotics/NSAID’s

Bleeding versus irreversible morbidity

Our strategy

• Recent cardial problems (stent, infarct) or stroke <6 weeks: Don’t touch

• No medication is stopped whatever implant treatment is planned

• conditions: INR not > 3 PTT not < 20 Atraumatic extraction therapy,

Local hemostasis, suturing, pression No NSAID Careful about meication interaction NO smoking

• Systematic pre-operative evaluation– Medical history– Clinical examination– Radiographic imaging

Bleeding - prevention

Bleeding - prevention

• Clinical examination, beware of:– Severe atrophy lower jaw– Lingual undercuts

44 42 32 34

• Systematic pre-operative evaluation– Medical history– Clinical examination– Radiographic imaging

Bleeding - prevention

Radiographic Imaging

? ? ? ? ? ?

CT or ConebeamCT

Mental nerve Lingual undercut

46 45 44 35 36 37

• Systematic pre-operative evaluation– Medical history– Clinical examination– Radiographic imaging

• Low-trauma surgery

Bleeding - prevention

• Systematic pre-operative evaluation• Low-trauma surgery

– Sharp instruments and burs– Constant cooling with saline during drilling– Gentle soft tissue handling

• keep periosteum intact

– Placement of retractors

Bleeding - prevention

• Handling– Compression– Ligation– Immediate referral to hospital

• R/ in the hospital– Observation– Drainage– Embolisation– Ev tracheostomy/ ICU

Bleeding - handling

Peri-operative complicationsOccurrence, prevention and handling

• Topics– Bleeding– Swelling– Root injury– Nerve injury– Displacement of implant– Infection– Pain– Fracture

Swelling - occurence

• A frequent complication in implant dentistry– Large inter-individual range– Increases with the extent of the surgical

procedure– Peaks within 36 hours– Not related to the survival of

oral implants– May cause discomfort and

reduced mouth opening and pain

Swelling - prevention

• No evidence from implant related studies, but from other oral surgery procedures:– Low-trauma surgery– Cold packings?

• No evidence of effect• Maybe an effect of the compression

Swelling - prevention

• No evidence from implant related studies, but from other oral surgery procedures:– Corticosteroids?

• Various regimens (i.v., i.m. and oraly) have shown significant effect on swelling and discomfort

• Suggestion: – Tabl. Methylprednisolon 32mg 1h pre-op– The day after: 16mg in the morning and 16mg in the

evening

Swelling - handling

• Information to the patient

Peri-operative complicationsOccurrence, prevention and handling

• Topics– Bleeding– Swelling– Root injury– Nerve injury– Displacement of implant– Infection– Pain– Fracture

Damage to neighbouring teeth - prevention

• Too narrow edentulous gap– Min 1.5mm to adjacent teeth (min. gap: 6-6.5mm)

• Non-parallel adjacent roots• False direction of implant preparation

– Anatomic landmarks– Use a drill guide

Non-parallel roots: result after 2 years of orthodonty

Damage to neighbouring teeth - prevention

Use of a drill guide to prevent root damage

Use of a drill guide to prevent root damage

Use of a drill guide to prevent root damage

Use of a drill guide to prevent root damage

Peri-operative complicationsOccurrence, prevention and handling

• Topics– Bleeding– Swelling– Root injury– Nerve injury– Displacement of implant– Infection– Pain– Fracture

Nerve injury- occurence

• Lower jaw– Alveolar nerve associated with

• Dorsal implants• Direct lesion of the mental nerve

• Upper jaw– Maxillary nerve

• Associated with long implants

• Our experience: all medicolegal problems we have in implantology are related to nerve injury, almost not related to implant failure

Nerve injury lower jaw- occurence

• Occurrence– Rare but severe

complication (>2%)– Most frequent in

patients with severe mandibular atrophy

• Almost exclusively related to the inferior alveolar nerve

Nerve injury - prevention

• Preoperatively– Proper radiographic imaging and preoperative

planning • Anterior region

– panoramic X-ray usually sufficient

• Posterior region– Mandibular canal must be visualised– CT scan or conebeamscan– At least simulation on implant planning software– Vertical safety margin: 2 mm

• No treatment is also an option !

Nerve injury - prevention

• Intra-operatively– Incision

• Releasing incisions at a safe distance from mental foramen

• Mental foramen may be located at the top of the crest in severe atrophic cases

– Expose mental foramen intra-operatively– Placement of retractor

Nerve injury - prevention

• Technical aids– Drill guide with vertical control or physical stop– (navigation techniques)

Physical stop

Nerve injury - prevention

SAFE System™ incorporated into a acrylic drill guide

Nerve injury - prevention

Nerve injury - prevention

Nerve injury - prevention

Nerve injury- prevention

Very experienced surgeon (with an off-day)

46 47

Nerve Injury -prevention

Surgeon used ultrashort implants but insufficient vertical height

Nerve injury - handling

• Post-operative neural disturbance may be the result of:– Compression, transection, tearing, laceration

or needle penetration– Local anaesthesie– Inappropriate incision design– Inappropriate handling of retractors– Drilling (depth, heating)

Nerve injury - handling

• Post-operative neural disturbance may be the result of:– Compression from implant, intraosseuous

bleeding/edema• Due to profuse bleeding during preparation :

intraoperative X-ray to check proximity to mand. Canal

• The patient reports altered sensation after LA wears off : re-check postop X-ray for proximity to mand. canal

Nerve injury - handling

• Post-operative neural disturbance may be the result of:– Compression from implant, intraosseuous

bleeding/edema• Possible effect of high dose NSAID and

corticosteroid (Ibuprofen 800mg, Prednisolon 50mg)• Suspicion of nerve laceration/transection or if no

improvement of altered sensation : referral to specialist

• Vitamin supplements no proven effect

Nerve injury – treatment options?

• Hypoesthesy– Wait and see a few weeks– Check radiologically on nerve impignment

• Complete anesthesy– If not integrated: remove implant– If integrated: apicectomy on the implant– Microsurgical nerve graft

Peri-operative complicationsOccurrence, prevention and handling

• Topics– Bleeding– Swelling– Root injury– Nerve injury– Displacement of implant– Infection– Pain– Fracture

Displacement of implant - occurrence

• May happen between implant insertion and second stage surgery

• Lack of primary stability• Few reported cases

– Maxillary sinus < 50 reported cases– Orbit– Anterior cranial fossa

X X

Displacement of implant - occurence

Displacement of implant - occurence

Displacement of implant - occurence

Displacement of implant - occurence

Displacement of implant - prevention

• Preoperatively:– Proper treatment planning – especially

radiographic imaging– Check subantral bone height and thickness

Dispacement of implant - prevention

• Intra-operatively:– Two-stage bone augmentation procedure if in

doubt of bone height and/or quality– Tapered implants / implants with cervical

collar– Bone condensation

Displacement of implant - handling

• Removal of implant– Antrotomy: removal of the implant– Removal of sinusal inflammation– Treatment of sinusal pathology

Peri-operative complicationsOccurrence, prevention and handling

• Topics– Bleeding– Swelling– Root injury– Nerve injury– Displacement of implant– Infection– Pain– Fracture

Infection - occurrence

• Infection is the most frequent cause of early implant loss– ~2-3%

Implants mandible Implants upper jaw Zygoma implant

Infection - prevention

• Avoid patients with compromised healing potential– Avoid

• irradiated areas• patients receiving i.v.

bisphosphonates– Be careful with:

• Immunocompromised patients• Heavy smokers• Diabetic patients with poor

glycemic control

Infection - prevention

• Avoid implantation into acute infected sites• Aseptic surgical technique• Chlorhexidine mouth-rinse

– Pre-operative– Post-operative

• Antibiotic prophylaxis ?

Effect of prophylactic antibiotics on implant survival

• See lecture of Marco Esposito

Peri-operative complicationsOccurrence, prevention and handling

• Topics– Bleeding– Swelling– Root injury– Nerve injury– Displacement of implant– Infection– Pain– Fracture

Pain - occurrence

• Postoperative pain may normally be considered mild– Highest pain intensity within the first 12 hrs

postoperatively (peeks after 3-5 hrs)

Pain - occurrence

• Severe pain after placement of dental implants is rare– A few cases of neuropathic pain have been

reported• May arise weeks or months after implant

placement• Difficult diagnosis – often multidisciplary treatment• Insufficient postoperative pain control may elicit

neuropathic pain

Rodriguez-Lozano et al. 2010

Unbearable pain requiring hospitalization

♀, 59j, 20 j edentulous, known with epilepsy, no other medical problems

X X

Pain - prevention

• Preoperative actions– Patient information

• Treatment course• Post-operative precautions• Most frequent complications

Pain - prevention

• Preoperative actions– Create a calm and trustful atmosphere– Evaluate need for sedation– Prescribe and inform about relevant

medication– Post-operative instructions in writing

A well-informed, trustful patient experiences less pain

Pain - prevention

• intra-operative precautions– Calm atmosphere (consider music)– Consider using LA with longer duration (like

Bupivacaine) in major procedures– Check sufficient effect of LA– Low-trauma surgery

Pain – prevention/handling

• Post-operative instructions– Physical rest (1-2 days)– Prophylactic pain killers should be started in

due time before LA wears off• NSAID (e.g. Ibuprofen 400mg x 4, Rofenid IM)• Synergistic effect of Paracetamol/Acetaminophen

(1g x 4)• May be combined with Tramadol/Codein

Pain – prevention/handling

• Post-operative instructions– Prophylactic coricosteroids and cold

packings?• No evidence of effect

– Laser?• No evidence of effect

– Acupuncture?• No evidence of effect

Peri-operative complicationsOccurrence, prevention and handling

• Topics– Bleeding– Swelling– Root injury– Nerve injury– Displacement of implant– Infection– Pain– Fracture

Mandibular fracture - occurrence

• A rare but severe complication– 0.2% of implants placed in edentulous

resorbed mandibles (anterior bone height <15mm)

– Requires most often hospitalisation and extensive reconstructive surgery

Raghoebar et al. 2000

Mandibular fracture - prevention

• Preoperative evaluation– Palpation– 3D-imaging– 1-2mm residual bone surrounding the

implants on the facial, lingual and apical aspects

– Consider the potential need for bone augmentation

Mandibular fracture - prevention

• Intra-operative evaluation– Short implants– Low-trauma surgery

• Postoperative evaluation– If implant mobility, suspect fracture

Peri-operative complicationsoccurrence, prevention and handling

• Conclusions – occurrence:– Peri-operative complications are rare (besides

swelling and mild pain) but probably underreported

– They may be potentially fatal or cause significant discomfort to the patient

Peri-operative complicationsoccurrence, prevention and handling

• Conclusions – prevention:– Most peri-operative complications can be

prevented by:– A systematic pre-operative evaluation incl. medical

history, clinical examination and radiographic imaging

– Pay special attention to • the severely resorbed anterior mandible (bleeding, nerve

injury, fracture)• Distal regions in the maxilla

– Low trauma surgery

Peri-operative complicationsoccurrence, prevention and handling

• Conclusions – handling:– Range from information – immediate referral

to hospital

Thanks for your attention !