DENTAL IMPLANTS : Surgical after-care and complications


The patient is provided with comprehensive post-operative instructions, suitable medication for pain control and prevention of infection and have a 24-hour emergency helpline directly to the surgeon.

Even if resorbable sutures have been used, patients should be routinely reviewed at between one to two weeks after surgery for suture removal. High standards of oral hygiene and general health should be maintained for the duration of the healing period.

Printed post-operative instructions and post-operative sundries such as ice packs, gauze and medication must be given to the patient prior to them leaving the surgery.

Patients should ideally be sent home under the guardianship of a responsible adult preferably by private transport.

See also: DENTAL ANESTHESIA : Mandibular Anesthesia : Gow-Gates technique


When the implants have been placed in the anterior mandible the patient should be warned regarding the risk of severe bleeding and swelling of the floor of the mouth occurring as this could potentially compromise the airway.

This would indicate a serious surgical emergency and hospitalisation.

Post-operative complications to look for:

• Infection
• Bleeding
• Pain
• Swelling and bruising
• Suture granuloma
• Wound dehiscence and break down
• Membrane exposures
• Altered sensation or numbness to teeth, gum, lip etc.
• Devitalisation of adjacent teeth

Damage to Inferior Alveolar Nerve

This can occur as a result of implant placement in close proximity of the IAN and particularly in case of poor surgical planning and/or technique.

Any report of paraesthesia or altered sensation occurring to the teeth, lip or the gum should be investigated urgently and the signs and symptoms should be recorded.

Early referral to an oral surgeon would be an advantage.

The ADI has developed and published a set of Guidelines on the prevention and management of inferior alveolar nerve damage. Please see the ADI website for more details.

Signs and symptoms of nerve injury:

• Pain
• Numbness or tingly sensation

Investigations

• Pin prick, 2 point discrimination, light touch and hot and cold tests
• An appropriate radiograph including CT scan if necessary
• A photograph documenting the size of the affected area.

Outcome

• Majority will fully recover
• A small minority will not recover
• Debilitating and lasting pain could be the most significant feature that might be difficult to manage.

Treatment

After assessment and diagnosis of the nature of the injury and the likelihood of spontaneous recovery of nerve function consideration should be given to:

a) decompression of the nerve injury by backing the implant out a few turns or complete removal
b) Medication: corticosteroids and other drugs
c) Microsurgical nerve repair on referral

Jaw Fractures

These are very rare. However, unexplained and prolonged source of pain after implant placement should be investigated to exclude the possibility of jaw fracture particularly in the mandible.

Premature Membrane Exposure

This could occur after implant placements and/or GBR. Higher incidence of membrane exposure has been reported with the use of nonresorbable or highly cross-linked collagen membranes, as these do not readily integrate with the wound through rapid transmembraneous vascularisation.

In these cases, the removal of the exposed membrane is advocated to reduce the risk of infection.

With resorbable membranes such as natural collagen, wound infection is not a common feature even if the membrane becomes exposed during healing, as these natural products have been shown to become rapidly vascularised through transmembranous infiltration of the microcirculation.

Use of chlorhexidine mouthwash is recommended in case of wound breakdown.

Infection

Localised infection at an implant site can arise from poor surgical technique, necrosis or contamination due to failure to reduce the bacterial count in the surgical field.

Smoking, uncontrolled diabetes and periodontal disease are risk factors. Very rarely severe or persistent infections could arise for no apparent reason.

There is some evidence that this may be due to activation of dormant foci of infections within the bone, which are impossible to identify in radiographs.

Osteomyelitis, although very rare has been reported after implant surgery. Patients presenting with post-operative infection should be investigated and followed up carefully to prevent the spread of infection systemically. Use of repeated doses of antibiotics blindly should be strongly discouraged.

Postoperative Pain

Clinical studies have shown that majority of patient’s report only mild discomfort and pain after straightforward implant placement surgery. This is normally controlled with paracetamol 500mg or ibuprofen 400mg. Prolonged or severe pain is unusual and therefore would warrant further investigations and diagnosis.

Maxillary Sinus Complications

Maxillary sinus can be involved either as part of the planned surgical procedure (closed or open sinus lift/grafting) simultaneously or in 2-stage procedure when placing implants.

In healthy individuals the success of bone regenerative procedures within the maxillary sinus cavity has been demonstrated to be safe and reliable.

Severe complications, however can arise due to poor surgical technique, infections and wound break down. Patient factors such as pre-existing sinus pathology, immunosuppression, medication, uncontrolled diabetes and periodontal disease also increase the risk of complications.

An infected sinus graft should be treated rapidly, preferably a referral to a specialist or more experienced clinician.

Displacement of Implants into Maxillary Sinuses This is being reported with increasing frequency. Retrieval of the implant preferably by endoscopic surgery is indicated to prevent the migration of the implant or damage to the sinus cavity.

adi.org.uk
Association of dental implantology




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