Introduction to implant-associated complications

Accidents and complication may happen during any surgical procedure. The effort that we can do to prevent these complications is a detailed treatment planning before stating the case and its appropriate execution. 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 implants have got a high rate 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 the complications that may occur 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 on a proper diagnosis and a well organized, thorough treatment plan. The patient selection, as well as identification of patient-associated risk factors, plays a very important role in implant success. Studies have demonstrated an association between risk factors and the rate of implant failure. Moy et al. (2005) 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 the risk of implant failure (RR = 2.24), along 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 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 planned.

     Of particular importance is the bone status in maxillary and mandibular posterior region where the availability of bone is less due to maxillary sinus and neurovascular bundle, respectively. Sinus uplift has become a routine procedure for implant placement in the maxillary posterior area. The nerve lateralization procedure is carried out in the mandibular posterior region to prevent any injury to 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. The necessary investigations, such as the study of models, radiographs or computed tomographic (CT) scans should be done for the appropriate treatment planning. Many implant-associated complications, 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.



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. The implant-associated complication can also be classified into the following categories,

Complications related to selection and placement of implant:
     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:
     Edema
     Emphysema
     Ecchymosis and hematoma

Let us discuss the above-mentioned complications in detail,

Complications related to selection and placement of implant

Improper selection of implant dimensions:

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 is 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 the implant and poor pre-operative treatment planning.

     Radiographic evaluation should be done to accurately determine the required length of the implant. The criteria of 2 mm safe zone should be followed, to be on the safer side. The 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 proper placement of the 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 the 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 implant and implant. Tarnow et al. (2000) 6 have shown in their study that an implant placed <3 mm away from an adjacent implant can have adequate stability and function initially, but may later result in the lateral bone loss. If more than one implant has 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.

     Angulation of the implant is also an important factor to be considered while placing implant. The angulation of the implant depends on 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 the 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 ……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..

     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 the 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:

Hemorrhage during the implant placement may occur due to three reasons, due to injury to a blood vessel during drilling, due to medical conditions like hemophilia or medications the patient is taking like anti-platelet aggregants. Patients treated with anticoagulant medication usually have a history of vascular or cardiac pathology (fibrillation, myocardial ischemia, valvular diseases or prosthesis, or thromboembolism) 10. The anti-coagulant therapy should be discontinued 1-2 weeks before the surgery with the consultation of the 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 INR of up to 2.5 12. If the INR is < 2.5, there is no need to discontinue the anti-coagulant therapy. Adequate hemostatic measures (suture, compression, use of hemostatic microfibrillar collagen gauzes, oxidized cellulose, absorbable 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 surgical techniques.

       Another reason for bleeding during surgery is the injury to the artery. It usually occurs in completely edentulous patients who have a deficit in the quality and quantity of bone. Bleeding may occur from the sublingual, lingual, peri mandibular, or submaxillary artery. It leads to the formation of a hematoma in the involved area. Uncontrolled bleeding may also occur during the 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 the injury to an artery in the area of the anastomosis involving posterior superior alveolar artery and the infraorbital artery. These arteries are the branches of the 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 and Zarb classification (1985) 14, the vessel is found >15 mm from the alveolar crest in class A, B, and C, ……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..

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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 the 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 to improper angulation of the drills. It has a bad prognosis because unlike the buccal region this area is not suitable for regenerative procedures.

     So, in short, it can be summarized that a thorough evaluation of CT scan of the area where implant placement is planned is a must, because it may reduce many implant placement related complications. It must be noted that if the implant exposure is equal to or more that 2/3rd of total implant length, the 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 the 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 neighboring teeth are closely placed. Another reason is dilacerated roots which may invade the implant space. This problem can be easily addressed by radiographic evaluation of the area as well as radiographic evaluation of guide pin at 5mm 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 neighboring tooth to implant. If the radiographic evaluation shows pathology associated with neighboring 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 on the bone density and cortical thickness. It is easy to achieve in mandible as compared to the maxilla due difference in bony architecture. It has been reported that implants with an insertion torque of value < 10 Ncm are at higher risk of osseointegration failure (type IV bone). Also, implants with too-high torque value > 45 Ncm are at high risk of failure due to bone compression, which causes bone necrosis (type I bone) 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 the fibrous encapsulation of the implant or in other words implant failure 22. Thus, achieving adequate primary stability is an important factor determining the implant success.

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 dense bone as compared to the 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 the implant sites at 2500 rpm 25. Bone tap is effective in reducing friction between the implant surface and bone. It allows passive implant fit, preventing implant-bone ……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..

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 of 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 the 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 ……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..

     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 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 also occasionally 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 the new implant.
  • Modification of prosthesis leaving the fractured portion of the 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 the 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 a 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 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 fiber-rich diet will help to eliminate the object. A gastroscopy or colonoscopy could also be mandatory in those cases in which the object remains stationary 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 the implant/implant kit components.

Complications associated with mandibular implant placement

Nerve injury:

During implant placement in the mandible, nerve injury may involve inferior alveolar, mental, incisive or lingual nerves. The best way to identify the location of the inferior alveolar canal in the computed 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 ……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..

     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 a 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 the case where the implant has already been placed and the radiograph reveals a close proximity or the invasion of the inferior alveolar canal, the implant should be immediately removed and a shorter body implant should be placed. The minor nerve injury heals within a few days, but major damage can take a longer time to heal. Although, the 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 anesthesia 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 “Clinical procedure for dental implant placement”.

Mandible fracture:

Mandible fracture is one of the complications when placing implants in an 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 for example 10 mm diameter site preparation for placing a 12 or 14 mm diameter implant, can cause excessive forces in the bone which may lead to fracture of the bone. The main treatment consists of the reduction and stabilization of the fracture with titanium miniplates 46, 47, or resorbable mini-plates. In the case of severely atrophic fractured mandible, two miniplates or a combination with microplates can be used as it is a 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 (1986) 49 for implant placement with desired bone height. The Schneiderian membrane is a thin layer of pseudociliated stratified respiratory epithelium laid on the 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 health and normal functioning 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 disruption of normal sinus physiologic function 52-60. However, no association ……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..

     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 “Clinical procedure for dental implant placement”.

     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 64. Valassis and Fugazzotto (1999) 65 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 easily repaired, while class IV is the most difficult to repair.

Class I
Perforation is adjacent to the osteotomy 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 the 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 a result of the 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 while 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 57, 66, 67, by placing a large lamellar bone sheet 65, 67, using a block graft inserted of a cancellous graft 60 or by the abandonment of the procedure 53, 54, 62, 68.

Implant displacement:

The implant may invade the maxillary sinus during or after the surgery as a result of an insufficient primary stability. The implant may get displaced into the maxillary sinus at any time after being placed. This can result in a foreign-body reaction and can serious complications. Maxillary sinusitis is a frequent complication of implant displacement into the maxillary sinus. The main reason for implant displacement is insufficient primary stability. The mechanisms involved in the implant displacement into the maxillary sinus include changes in intrasinal and nasal pressures, the autoimmune reaction causing bone destruction and hence poor osseointegration and bone resorption due to the unfavorable distribution of occlusal forces 69. 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 the 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 provides good access to the area and has lower post-operative morbidity 70, 71. 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 ……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..

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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 72. Postoperative acute maxillary sinusitis may cause implant and graft failures. Maxillary sinus has got an efficient mechanism of drainage. The disturbance in the mucociliary flow pattern due to the foreign body causes accumulation of fluid in the sinus leads to sinusitis. Inflammation of the sinus membrane also occurs due to non-vital bony fragments floating freely in the maxillary sinus. The patency of the ostium must be maintained, because, in the absence of drainage, the maxillary sinus quickly became obstructed, inflamed, and then infected 73.



Other complications

Edema:

Edema is a common complication after surgical procedures. It usually appears 24 hours after the surgery. During implant therapy elevation of the wider flap, bone regenerative surgery, and duration of the surgery are the major factors related to the appearance of edema. Analgesic and anti-inflammatory drugs are given to reduce inflammation and serratiopeptidase are given to reduce edema 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 postoperative edema 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 edema can easily be avoided by careful handling of soft tissue, less operative time, use of a cold pack, and non-steroid anti-inflammatories drugs. Administration of corticosteroids for a short term is very helpful in cases where post-operative edema is suspected.

Emphysema:

This is a rare complication but can lead to serious consequences. It is caused by the inadvertent insufflations propulsion of air into tissues under the skin or mucous membranes. Air gets entrapped into the facial planes and creates a unilateral enlargement of the fascial and/or submandibular 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 74. This complication does not usually happen during the implant placement procedure as high-speed hand pieces are not used. It usually happens during maintenance of implants or cleaning the implant surface. The treatment includes close observation, the patient is given antibiotics and analgesics, light massage of the area and applications of the heat pack. The condition usually resolves within 3-10 days, but if the condition of the patient worsens due to any reason, physician help should be taken with the proper examination, including the computed tomogram (CT) scan to find out the extent of involvement.

Ecchymosis and hematoma:

Due to the accumulation of blood in the submucosa or subcutaneously, hematoma and ecchymosis 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 ……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..Contents available in the book……..

     In certain cases, severe bleeding in the floor of the mouth may result in the formation of a large hematoma. The hematoma may involve sublingual, submandibular, and submental spaces causing swelling of the floor of the mouth and elevation and posterior displacement of the tongue with upper (oropharyngeal) airway obstruction similar to Ludwig’s angina. In such a case, security airway patency should be the first management step by using Guedel pattern airway. If the patient is able to breathe autonomously with good oxygen saturation value, intubation or tracheostomy is not necessary.

Conclusion

Complications during implant therapy are a result of 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 the 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 for the patient can be achieved.

References

References are available in the hard-copy of the website.

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