Dental implant complications: their prevention and management

Introduction:

Accidents and complication may happen during any surgical procedure, if not in one patient then may be in another patient. The only relevant question is how often they happen with you? The effort we can make to prevent these complications is, a thorough knowledge of the subject and proper homework before stating the case. Although, we can’t totally eliminate the complications but by doing this we can definitely minimize their frequency of occurrence. 

No doubt, dental implant therapy has provided us with a very promising treatment for partially and fully edentulous patients. Use of endosseous implants for the rehabilitation of edentulous or partially edentulous patients has become a standard of care in the past two decades. Studies have shown that implant have got a high rates of success 1-4. But it does not mean that implant therapy is free of complications and failures. It is very important to understand the complications that may occur during implant placement and post operatively to efficiently plan the treatment and to minimize implant failures. In the following sections we shall discuss all the complications that may happen during and after implant placement and also how to handle these complications.

Importance of diagnosis and treatment planning:

Long term success of implant therapy depends upon a proper diagnosis and a well organized, thorough treatment plan. The patient selection as well as recognition of patient associated risk factors plays a very important role in implant success. Studies have demonstrated association of risk factors with rate of implant failure. Moy et al 5 in their 11 year retrospective study demonstrated that the relative risk ratios (RR) with increasing age (60–79 y/o) had a strong association with implant failure (RR = 2.24) and also with smoking (RR = 1.56), diabetes (RR = 2.75), head and neck radiation (RR = 2.73), and postmenopausal estrogen therapy (RR = 2.55). Along with this the quantity and the quality of the available bone for implant placement also plays an important role. If it is suspected that the bone available is insufficient, bone augmentation procedures are recommended.

Of particular importance is the bone status in maxillary and mandibular posterior regions where availability of bone is less due to the presence of maxillary sinus and neurovascular bundle respectively. Sinus uplift has become a routine procedure for implant placement in maxillary posterior areas in case of insufficient bone. Nerve lateralization procedure is carried out in the mandibular posterior region to bypass the neurovascular bundle.

The medical history of the patient is of particular importance. Uncontrolled diabetes mellitus is one major reason for delayed healing. It may hamper the healing process and hence osseointegration of the implant. Any medical condition that prevents the surgical procedure to be performed like bleeding disorder must be taken into consideration. If the patient is under a platelet antiaggregant treatment on a daily basis, appropriate steps should be carried out to restore normal clotting time.

It is important to emphasize here that after critical evaluation of the case once it is finalized that patient is an acceptable implant candidate, the risk shifts on the clinician for proper planning and delivering the case. Clinician’s knowledge, clinical ability and experience in implant dentistry are the critical factors that determine the success of therapy.

Proper diagnosis requires proper investigations. If a patient refuses necessary diagnostics, such as radiographs or study models, you should refuse to treat, because later on for any reason if the implants fail the clinician is accounted responsible for that. Many implant treatment claims, such as those including sinus perforation, nerve damage and poor angulation resulting in the inability to restore an implant, can be attributed to a lack of pre-surgical planning. Once you are sure about the outcome of the implant therapy, you should agree to take up the case. The clinical experience plays an important role here. More cases you do, better you can predict the outcome of the case.

Classification of complications during implant therapy:

The complications related to implant therapy may be divided into early and late complications. Early complications include: implant fracture, bleeding, ecchymosis and hematoma, edema, soft tissue dehiscence of the area, infection, emphysema and alterations in sensation. Late complications include mucoperiosteal flap perforations, maxillary sinusitis, mandibular fractures, loss of osseointegration, peri-implantitis.  For the ease of understanding let us classify the complications associated with implant therapy as,

Complications related to treatment Planning:

Improper selection of implant

Improper placement of implant

Improper angulation of implant

General Procedural complications:

Bleeding

Cortical plate perforation

Devitalization of adjacent teeth

Lack of primary stability

Mechanical complications

Implant fracture

Ingestion/aspiration

Complications associated with mandibular implant placement:

Nerve injury

Mandible fracture

Complications associated with maxillary sinus lift

Schneiderian membrane perforation

Implant displacement

Postoperative maxillary sinusitis

Other complications

Oedema

Emphysema

Ecchymosis and hematoma

Let us discuss the above mentioned complications in detail,

Complications related to treatment Planning:

Improper selection of implant:

Selection of the proper implant fixture (length, diameter, and design) appropriate for the implant site and function is the first and foremost important step in implant therapy. Paresthesia or anesthesia secondary to implant placement are due to the placement of a fixture that was too long for the available site, resulting in nerve injury. Implant projecting in the sinus is due to excessive length of implant and poor pre-operative treatment planning.

Radiographic evaluation should be done to accurately determine length of the implant. The criteria of 2 mm safe zone should be followed to be on the safer side. Diameter of the implant should be determined on the basis of clinical availability of bone. The minimum bone thickness around implant should be 1.5-2 mm. If the alveolar bone ridge is thin for the placement of a proper diameter implant, splitting the alveolar bone can be done.

Improper implant placement:

The placement of implant is critical for long term implant success. Precise implant placement requires space analysis as well as occlusal analysis which can be easily done on articulated cast model. Rule of thumb is that we must have 1.5-2 mm of bone between tooth and implant and 3-4 mm of bone between adjacent implants. Tarnow et al have shown in their study that an implant placed <3 mm away from an adjacent implant can have adequate stability and function but may later result in lateral bone loss 6. If more than one implant have to be placed, a diagnostic wax-up should be made to correctly identify implant locations. The measurements on the cast model are very useful in calculating the total space available and the size of implants that can be placed.

Improper angulation of implant:

The angulation of the implant depends upon two factors viz. the anatomy of available bone and future prosthesis. The bucco-lingual, apico-coronal, and mesio-distal angulation should be carefully evaluated. Deliberate attempt to change angulation of the implant to facilitate parallelism or future prosthesis fabrication may lead to the perforation of cortical bone or damage to the adjacent teeth. If an unfavorable implant angulation is achieved due to anatomical limitations, angled/custom made abutments are used to facilitate the prosthetic rehabilitation. Best way to avoid improper implant angulation is to use a surgical implate/surgical guide with long drill channels. Also, after using pilot drill the paralleling pin may be placed in osteotomy and radiograph taken to check any improper mesiodistal angulation. If it is present large diameter drills are used correct the angulation. It should be remembered that while doing that too much manipulations should not be done as it may hamper the primary stability of implant.

Every attempt should be done to place the implant in the natural angulation of tooth. For example, mandibular teeth in the natural dentition are lingually inclined at an angle of approximately 109 degrees in relation to the maxillary arch dentition 7 as well as mandibular base 8.

One interesting reason of improper implant angulation is finger rest. Dentists have traditionally been taught to stabilize their hands by placing a finger on adjacent teeth or the chin while using instruments/ handpieces during periodontal and operative work to stabilize the hand as well as to reduce the muscle fatigue 9. The finger rest should not be taken while placing implant. Because the length of the implant drill varies from around 10-20 mm, using a finger rest while drilling, results in an inclination of the drill towards the hand that is steadied.

General Procedural complications:

Bleeding:

Haemorrhage during the implant placement may occur due to three reasons, due to injury to a blood vessel during drilling, due to medical condition like haemophilia or medications the patient is taking like anti platelet aggregants. Patients treated with anticoagulant medication usually have history of vascular or cardiac pathology (fibrillation, myocardial ischemia, valvular diseases or prosthesis, or thromboembolisms) 10. The anti-coagulant therapy should be discontinued 1-2 weeks before the surgery with the consultation of patient’s physician to normalize clotting time 11. But, before we discontinue the anti-coagulant therapy the International Normalized Ratio (INR) should be tested. The British Committee for Standards in Haematology advises that minor surgery can be performed with an International Normalized Ratio (INR) of up to 2.5 12. If International Normalized Ratio (INR) is < 2.5, there is no need to discontinue the anti-coagulant therapy. Adequate hemostatic measures (suture, compression, the use of hemostatic microfibrilar collagen gauzes, oxidized cellulose, reabsorbable fibrin, or mouth rinsing with 4-8% of tranexamic acid) are followed during the surgery and at the same time, efforts are made to use atraumatic surgery techniques.

Other reason for bleeding during surgery is the injury to the artery. It usually occurs in totally edentulous patients who have a deficit in the quality and quantity of bone. Bleeding may occur from sublingual, lingual, perimandibular, or submaxillary artery. It leads to formation of hematoma in the involved area. Un-controlled bleeding may also occur during maxillary sinus lift. The blood supply of the maxillary sinus is derived from the infraorbital artery, the greater palatine artery and the posterior superior alveolar artery. This bleeding is usually due to lesion involving an artery that joined by anastomosis the posterior superior alveolar artery and the infra-orbital artery. These arteries are the branches of maxillary artery having an intraosseous course usually at 16.4 mm from the bone crest 13. The position of the vessels may vary with the resorption of the alveolar ridge. According to Lekholm & Zarb classification (Lekholm & Zarb, 1985) 14 the vessel is found >15 mm from the alveolar crest in class A, B and C, but in classes D and E, the value is >7 mm (mean 10.4 mm). So, it is recommended that in case of class A, B and C the superior border of the osteotomy can be placed upto 15 mm from the alveolar crest. But, in case of class D and E because of less space available from the alveolar crest there are higher chances of vessel injury.

So, it is better to go through the extensive tomography of the area planned for surgery before carrying out the procedure.

Cortical plate perforation:

It is a common problem that happens when the implant is placed too buccally or the buccolingual angulation of the implant is not maintained. Two types of defects are found in case of cortical bone perforations: fenestration and dehiscence. A fenestration leaves intact bone coronally with the exposed threads at the apical portion of the implant, whereas a dehiscence defect has the coronal portion of the implant exposed with apical bone intact. During implant placement if any of these defects is encountered, immediate correction with particulate bone grafting with or without a membrane can be done as long as the primary stability is achieved. The flapless implant surgeries should be avoided in cases where the alveolar process is thin and a perforation is suspected.

Sometimes, during the immediate implant placement after extraction the fenestration and dehiscence may go un-noticed. It is recommended that in suspected cases the exploration of the alveolar process should be done after osteotomy and before implant placement to detect any discontinuity in the bone 16. The perforation of the lingual cortical plate in the inter-mental region is commonly encountered due improper angulation of the drills. It has a bad prognosis as unlike the buccal region this area is not suited for regenerative procedures.

So, in short it can be summarized that thorough evaluation of CT scan of the area where implant placement is planned is must as it may reduce number of implant complications. It must be noted that if the implant exposure is equal to or more that 2/3rd of total implant length, implant should be removed and bone graft with/without barrier membrane should be placed to re-attempt the procedure after 6-8 months.

Devitalization of adjacent teeth:

Due to improper mesiodistal placement of the implant injury or devitalization of the adjacent teeth may occur. This problem arises more frequently with single implants where the roots of the neighbouring teeth are closely placed. Another reason is dilacerated roots which may invade the implant space. This problem can easily be addressed by radiographic evaluation of the area as well as radiographic evaluation of guide pin at 5 mm depth to determine the angulation of the osteotomy 17.  Use of surgical guide is very helpful in maintaining the angulation of the implant. As a rule a space of 1.5-2 mm should be maintained between tooth and implant. The devitalization of the injured tooth requires endodontic therapy. 

Another point to note here is spread of infection from neighbouring tooth to implant. If the radiographic evaluation shows pathology associated with neighbouring tooth, it should be treated before implant placement. Many reports have reported the implant pathosis caused by dormant endodontic problems of adjacent teeth that flare up after implant surgery 18-20.

Lack of primary stability:

The primary stability of the implant depends upon the bone density and cortical thickness. It is easy to achieve in mandible as compared to maxilla due difference in bony architecture. It has been reported that implants with insertion torque of value < 10 Ncm are at higher risk of osseointegration failure (type bone IV). Also, implants with too-high torque value > 45 Ncm are at high risk of failure due to bone compression which causes bone necrosis (type bone I) 21.

Achieving a primary stability is a major requirement of implant therapy. Lack of primary stability is a surgical complication that should be dealt with at the time of implant surgery. If the implant is unstable, it should be removed and a wider diameter implant should be placed. It has been reported that leaving an unstable implant in bone leads to fibrous encapsulation of the implant or in other words implant failure 22.

Mechanical complications:

The mechanical complications include overheating of the bone and soft tissue injuries. The critical temperature of bone cells is as low as 47˚C at an exposure time of 1 min. Above this temperature the main bone cell enzyme alkaline phosphate denatures 23. Overheating is more common with dense cortical bone  (type I bone quality) as compared to type III or IV soft cancellous bone during preparing osteotomies because more pressure is needed to advance the drill apically in comparison to soft bone. According to Misch using external and/or internal irrigation, as well as cool saline irrigation, intermittent pressure on the drills, pausing every 3 to 5 seconds, using new drills, and an incremental drill sequence can effectively reduce the heat production during drilling 24. Heat generation can also be reduced by preparing implant sites at 2500 rpm 25. Bone tap is effective in reducing friction between implant surface and bone. It allows passive implant fit, preventing implant-bone interface microfracture, and compression necrosis, and removing drill remnants 26. The major reasons for early implant failure are excessive surgical trauma along with impaired wound healing, premature loading and infection 27.

Along with the hard tissue over heating lesions may be seen in soft tissue also. Burn lesions on the labial mucosa resulting from overheating of the hand piece head have been reported. Care should be taken to avoid overheating of the hand piece.

Implant fracture:

The incidence of dental implant fracture is between 0.16 – 1.5 % of cases 28-37. There are two main causes for late implant fracture: First, Mechanical overload on implant causes metal fatigue and when the resistance limit is exceeded, fracture results. Second, the loss of supporting tissue secondary to infection (peri-implantitis) or occlusal trauma 38-39. One more factor suggested for implant fracture is galvanic corrosion 40. It has been reported that when vertical bone loss coincides with the apical limit of the screw joining transepithelial abutment to implant, the risk of implant fracture increases considerably 36. The defects in the manufacturer’s design and production are the least likely but one of reasons for implant fracture.

Mechanical overloading is mainly because of two reasons: parafunctional habits and improper prosthetic design of the framework. Extreme bruxism and clenching habits are one of the most important causes of implant fracture. The bending forces in posterior quadrants especially in patients with bruxism cause excessive forces on the implant predisposing them to fracture. The prosthetic framework should be designed carefully. Tooth/teeth should be in occlusal harmony and no premature contact should be present in centric as well as eccentric positions.

The accurate fit of the prosthesis is important for implant success. If the prosthetic framework is ill fitting, it can result in constant shear load on the implant predisposing the implant for fracture. The bending forces on the implant are most deleterious to implant and are most commonly related to implant fracture. Usually the implant fracture in these cases is preceded by loosening of the screws. This should be regarded as a warning sign and implant framework should to be corrected before the implant fractures.

The clinical features of implant fracture include spontaneous bleeding and mobility. Clinical examination confirms increased mobility, increased pocket depth and gingival indexes, and occasionally also plaque accumulation resulting from patient fear of the pain triggered by brushing. Radiological examination confirms separation of the fragments and bone loss.

Three management options have been described in the event of implant fracture 28, 41:

  • Complete removal of the fractured implant using explantation trephines and placement of new implant.
  • Modification of prosthesis leaving the fractured portion of implant in place.
  • Removal of the coronal portion of the fractured implant, leaving the remaining apical part integrated in the bone.

Ingestion/aspiration:

Ingestion or aspiration of implant component is an embarrassing situation. Although a proper protocol of taking the implant/implant component directly from the tray to site of implant placement should be followed but accidents may happen. The situation sometimes may become life threatening. Although instruments have been designed to ensure screws and abutments transfer directly from the surgical tray into the patient’s mouth but preventative measures such as gauze throat screens and floss ligatures on implant pieces should be followed. If the patient swallows or aspirates an implant component, they should be referred to the hospital. Sometimes the aspirated component may cause airway obstruction thus creating life threatening condition. If the foreign object is aspirated it should be removed within 24 hours because prolonging the removal of foreign objects may make a bronchoscopy technically more difficult 42.

In cases where the foreign object has entered the digestive system, a series of post-operative controls with the help of radiological imaging are followed. A rich diet in fiber will help to eliminate the object. A gastroscopy or colonoscopy could also be mandatory in those cases in which the object remains stationery in the intestinal tract.

All these complications can be avoided by carefully handling the instruments during the surgery as well as attaching floss ligatures on implant/implant kit components.

Complications associated with mandibular implant placement:

Nerve injury:

During implant placement in mandible nerve injury may involve inferior alveolar, mental, incisive or lingual nerves. Best way to identify the location of inferior alveolar canal in the computer tomography (CT) scan. The cortical bone offers resistance while drilling due to its high density but when the drill reaches the cancellous bone, the resistance is less and the drill may drop into the neurovascular bundle. It has been suggested that during mandibular implant placement, a local infiltration rather than mandibular nerve block should be given. By this we can avoid the drill approaching too close to the canal. A study done on human cadavers has suggested a safety zone of 1-2 mm as provided by the radiographs during surgery 43.  

Chair-side method to avoid mandibular nerve injury is making an osteotomy 2 mm short of the desired length and taking a radiograph after placing paralleling pin in the osteotomy. If the distance between the mandibular canal and the base of osteotomy is less the implant length should be re-evaluated. In case where implant has already been placed and radiograph reveals close proximity or invasion of inferior alveolar canal, the implant should be immediately removed and a shorter body implant should be placed. The minor nerve injury heals within few days but major damage can take longer time to heal. Although drugs are not of much help but drugs of choice for nerve injury include neuronal anti-inflammatory drugs such as clonazepam, carbamazepine or vitamin B-complex 44. It has been suggested that if total anaesthesia persists or dysesthesia remains for more than 16 weeks, the patient should be referred for microneurosurgery to establish nerve continuity 44, 45. Techniques of managing neurovasculature in atrophied mandible have been discussed in detail in “Dental implants: Mandibular neurovascular considerations”.

Mandible fracture:

Mandible fracture is one of the complications when placing implant in atrophic mandible. Many factors are responsible for the fracture of the mandible during implant placements which include: quality and the quantity of the remaining bone, wrong size of the implant, osteoporosis in females and improper surgical technique. Placing an over-sized implant or preparing an under sized osteotomy can cause excessive forces in the bone which may lead to fracture of the bone. The main treatment consists in the reduction and stabilization of the fracture with titanium miniplates 46, 47, or resorbable miniplates. In case of severely atrophic fractured mandible, two miniplates or a combination with microplates can be used as it is less invasive treatment and stable fixation can be achieved 48.

Complications associated with maxillary sinus lift

Schneiderian membrane perforation:

The maxillary posterior area presents a major challenge for placement of implants when there is minimal residual crestal bone (< 5 mm) for stability. Maxillary sinus up-lift is the procedure of choice as demonstrated by Tatum 49 for implant placement with desired bone height. Schneiderian membrane is a thin layer of pseudociliated stratified respiratory epithelium laid on periosteum lining the maxillary sinus. It is an important barrier for the protection and defense of the sinus cavity and is essential in maintaining the healthy and normal function of the maxillary sinus 50. Perforation of Schneiderian membrane during sinus up-lift procedure is a common complication. The perforation may result in graft migration or loss, exposure of the graft or the implant to the sinus, and postoperative site infection. Also, due to disruption of the mucosa the normal mucociliary flow pattern is disturbed leading to retention of secretions in the sinus as well as infections around the foreign body 51. According to the literature, the membrane perforation is strongly associated with the appearance of postoperative complications and consist mostly of acute or chronic sinus infection, bacterial invasion, swelling, bleeding, wound dehiscence, loss of the graft material and a disruption of normal sinus physiologic function 52-60. However, no association has been found between membrane perforations or postoperative complications and implant survival 56, 61-63.

One study 64 done on dogs to investigate maxillary sinus complications in implants which penetrated the bone and mucous membrane of the sinus floor at 2, 4, and 8 mm extensions did not demonstrated any signs of pathologic findings in the maxillary sinus of the 8 dogs after 6 months. But, 6 months is not a long enough time to evaluate the long term consequences of maxillary sinus perforation.

It is recommended that the continuity of the Schneiderian membrane should be maintained while doing a sinus lift procedure. Although it is a technique sensitive procedure but membrane perforation can be avoided by carefully relieving the membrane from the bone. The detailed description of the sinus lift procedure has been given in “Maxillary sinus floor augmentation procedure.”

In case of perforation of Schneiderian membrane during the sinus floor elevation and augmentation, many treatment modalities have been advocated. When the perforation is small and located in an area where the elevated mucosa is folded together, it will be healed by itself. If the perforation is large and located in an unfavorable area, the perforation needs to be closed in order to prevent loss of the bone graft 65. Valassis and Fugazzotto 66 have given a classification of maxillary sinus perforation which is based on both position and extent of perforation. Class I and class II perforations are most easily repaired, while class IV is the most difficult.

CLASS I

Perforation is adjacent to the osteomy site. Class I perforations are often “sealed off” as a result of the membrane folding upon itself following completion of elevation. Treatment should be considered when the perforation is still evident after membrane reflection.

CLASS II

A class II perforation is located in the mid superior aspect of the osteotomy, extending mesiodistally for two thirds of the dimension of total osteotomy site. A class II perforation occurs most frequently when in-fracture design of the osteotomy is employed. Repair and treatment are similar to those for class I

CLASS III

A class III perforation is located at the inferior border of the osteotomy at its mesial or distal sixth. This is the most common perforation and is almost always the result of inadequacy of osteotomy or improper execution of membrane reflection. Completion of membrane refraction rarely results in covering a class III perforation and treatment is needed.

CLASS IV

A class IV perforation is located in the central two thirds of the inferior border of the osteotomy site. Such a perforation is relatively rare and is almost always caused by lack of care when preparing the osteotomy site and represents a considerable clinical challenge.

CLASS V

A class V perforation is a pre-existing area of exposure of the sinus membrane, due to a combination of extensive antral pneumatization and severe ridge resorption.

The recommended procedures for large perforations are using a bioabsorbable membrane 67-69, by placing a large lamellar bone sheet 66 70, using a block graft inserted of a cancellous graft 71 or by abandonment of the procedure 53, 54, 63. The detailed description of management of Schneiderian membrane perforation has been discussed in “Maxillary sinus floor augmentation procedure.”

Implant displacement:

The implant may invade the maxillary sinus during or after the surgery as a result of an insufficient primary stability. Implant may get displaced into the maxillary sinus at any time after being placed.  This can result in a foreign-body reaction and cause serious complications. Maxillary sinusitis is a frequent complication of implant displacement into maxillary sinus. The main reason for implant displacement is in-sufficient primary stability. The mechanisms involved in the implant displacement into the maxillary sinus include: changes in intrasinal and nasal pressures, autoimmune reaction causing bone destruction and hence poor osseointegration and bone resorption due to unfavourable distribution of occlusal forces 73. The negative air pressure created in the maxillary sinus may produce a suction effect causing the implant to move into the sinus. Whatever may be the reason, when implant has been displaced into the sinus, it must be removed. It is recommended that implants must be immediately retrieved surgically via an intraoral approach or endoscopically via the transnasal route to avoid inflammatory complications. The Caldwell-Luc procedure offers better direct visual access to the maxillary sinus as compared to the endoscopic approach, but is considered more aggressive with potentially more serious complications. Endoscopic access via transnasal route provide good access to the area and has lower post-operative morbidity 74, 75. In endoscopic transnasal maxillary sinus surgery the access to the maxillary sinus is achieved through the nose via the ostium. Using a urological retrieval basket through the endoscopic working channel port, the implant is captured and removed.

As described above the main reason for implant displacement is lack of primary stability. This complication can easily be avoided by correctly following the surgical technique. If it is appreciated that the bone quality is not good, the osteotomy should be prepared to a smaller diameter to that of the fixture so that when implant is placed we can achieve the minimum primary stability.  Implants with a conical compressive form can be used in areas where this problem is suspected.

Postoperative maxillary sinusitis:

Post-operative maxillary sinusitis can occur as a result of contamination of the maxillary sinus with oral or nasal pathogens. Investigations have reported maxillary sinusitis up to 20% of patients after sinus floor augmentation 76. Postoperative acute maxillary sinusitis may cause implant and graft failures. Maxillary sinus has got an efficient mechanism of drainage. The disturbance in mucociliary flow pattern due to foreign body causes accumulation of fluid in the sinus causes sinusitis. Inflammation of the sinus membrane also occurs due to non-vital bony fragments floating freely in the maxillary sinus. The patency of the osteum must be maintained because in the absence of drainage the maxillary sinus quickly became obstructed, inflamed, and then infected 77.

Other complications:

Oedema:

Oedema is a common complication after surgical procedures. It usually appears 24 hour after the surgery. During implant therapy elevation of wider flap, bone regenerative surgery and duration of the surgery are the major factors related to appearance of oedema. Analgesic and anti-inflammatory drugs are given to reduce inflammation and serratiopeptidases are given to reduce oedema in these cases. Serratiopeptidase or serrapeptase is a protein (proteolytic) enzyme isolated from the non-pathogenic enterobacteria Serratia E15 found in silkworms. The mechanism of action of Serratiopeptidase appears to be hydrolysis of histamine, bradykinin and serotonin. Serratiopeptidase also has a proteolytic and fibrinolytic effect.

The post operative oedema is significantly less in flapless implant surgeries due to less involvement of the soft tissue. This is also appreciated in immediate post extraction implant placement. Post-operative oedema can easily be avoided by careful handling of soft tissue, less operative time, use of a cold pack, and non-steroid anti-inflammatory drugs. Administration of corticosteroids for short term is very helpful in cases where post-operative oedema is suspected.

Emphysema:

This is a rare complication but can lead to serious consequences. It is caused by inadvertent insufflations propulsion of air into tissues under skin or mucous membranes. Air gets entrapped into the facial planes and creates a unilateral enlargement of the fascial and/or sub-mandibular regions. The clinical symptoms include the crackling sensation (crepitation on palpation) as the gas is pushed through the tissue.

It is usually caused by the entrapment of air into the tissue while using compressed air in air rotor hand piece, air/water syringe, an air polishing unit or an air abrasive device 78. This complication does not usually happen during implant placement procedure as high speed hand pieces are not used. It usually happens during maintenance of implants or cleaning the implant surface with a laser device to remove residues from an implant surface.

The treatment includes close observation, patient is given antibiotics and analgesics, light massage of the area and applications of heat pack. The condition usually resolves within 3-10 days but if conditions of the patient worsens due to any reason physician help should be taken with proper examination including the computed tomogram (CT) scan to find out the extent of involvement. 

Ecchymosis and hematoma:

Due to accumulation of blood in the submucosa or subcutaneously hematoma and echymosis are formed. Although they are not so common, but due to improper handling of the soft tissue and due to patient factors like bleeding conditions or anti-coagulant therapy these may occur. The complete hemogram with coagulation tests should be done prior to surgical intervention. If during the surgery it is suspected that there is heavy bleeding due to injured blood vessel bimanual compression at the suspected site of perforation should be applied to control bleeding. After applying all local haemostatic measures if the bleeding still persists, the patient should be transferred to nearest hospital to secure the airway without delay. After the airway is secure all the measures of stopping the bleeding can be undertaken. Ligation of the injured vessel should be performed if the vessel is identifiable.  Extra-oral ligation of the feeder vessel is the last measure for stopping the bleeding.

Conclusion:

Nobody wants to see complications during implant therapy. But, complications happen and these complications make us understand the subject better, as well as the deficiency in our treatment planning. Although, surgical procedures have been refined to aid the clinician during implant placement but the basic principles remain the same. The bone has to be respected and handled carefully to avoid any error from our side. A thorough treatment planning as well as an accurate execution of the treatment plan makes implants successful.  A long term functional stability of implants is the desired outcome of implant therapy. The clinical and radiographic analysis are the cornerstones of treatment planning of an implant case. Study model analysis is very helpful in doing space analysis and identifying location, number and size of the implants. If all these procedures are followed, the operative and the post operative complications related to implant therapy can be effectively avoided and satisfactory results both for the dentist as well as patient can be achieved. 

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