peri-operative complications luc vrielinck
DESCRIPTION
Peri-operative complications Occurrence, prevention and handling Dr. Luc Vrielinck Peri-operative complications Occurrence, prevention and handling • The presentation is mainly focused on standard implant placements without soft and hard tissue augmentation procedures Peri-operative complications Occurrence, prevention and handling • Topics Peri-operative complications Occurrence, prevention and handling • Topics – Rare – Potentially life-threatening • Severe haemorrhageTRANSCRIPT
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 !