Implant may have perforated lingual cortical plate: options?
I had placed an implant at #31 after grafting with cortical/cancellous mix FDBA and 6 months of healing. The patient had very limited opening, and as a result, the implant is tipped distally by about 20 degrees. The only thing is, with my last drill, there was copious bleeding from the osteotomy site, but it was stopped by the insertion of the implant.
The implant is very far from the inferior alveolar nerve (IAN), but I am concerned that I may have perforated the lingual cortical plate as the last drill did meet some resistance (although it was all type I bone). In addition to this bleeding from the osteotomy, I had to place the implant very close to the lingual edge of the ridge, b/c of access. His opening did not allow me to place drills in ideal position.
Also, I am also concerned whether restoratively, this is feasible and whether it will last in the long run, especially where occlusal forces are so strong at this site.
Patient is healing well with no pain, no numbing, and no intraoral swelling, no bleeding.
Should I order a post-op CT scan for that quad (the imaging center has sectional CT) just to be sure? If it’s really perforated by less than 20%, and pt has no symptoms, should I leave it or remove it? What options do I have if access is a problem? Refer to someone who does Bicon?
Thanks!
13 Comments on Implant may have perforated lingual cortical plate: options?
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CRS
3/13/2014
I'm curious what do you mean by less than 20%? Perhaps due to the limited access you should have stopped and not placed an implant in the second molar region. I think a CT is advisable before proceeding further. Good Luck.
ALPC
3/19/2014
Hi Everyone,
A colleague here is asking for help.
Comments like "you should have stopped and not place an implant" or "mouth opening is a relative contraindication", is not helpful. If you have all placed implants perfectly without ever having a complication then congratulations - you have my vote for sainthood. If not then why don't we give our colleague, who has entrusted this forum, left his ego at the door, asking for expertise and mentorship of his fellows, something meaningful to work with? The purpose of the forum is to troubleshoot and not be a sitting duck for legal wannabes.
In my years of being a moderator of groups of people, including dentists, the etiquette is never to say "you" but instead say"if it were me this is what I would do" or "If I may offer this I would approach it this way...".
In the end its all about respecting the other individual in any dialogue, and bedside manners, whether in the clinic or on a forum is, with all due respect, appreciated under all circumstances.
Thank you.
As for a solution, I am still thinking about a meaningful reply as I have not had this experience before.
CRS
3/20/2014
Sometimes it is difficult to give advice when having to weigh ones words and be concerned about how the advice will be taken and whether or not the persons feelings will be hurt. If the individual does not like the answer then perhaps the question should not be posed. Based on the information given here, limited opening,20 degree distal tilt, copious bleeding, possible lingual perforation and 20% the case is going south for many reasons and the operator is not seeing that. Now I see a post on how my comments should be more considerate. Quite frankly over the year and a half I have been reading this blog I am shocked at how many times the same errors are being posted and how it us okay to be learning on patients. There are many people out there placing implants who are not adequately trained and are getting into trouble but this seems to be okay also. Often extraneous material gets mentioned about how another person would also make a mistake as this which I don't see how that has anything to do with this set of facts. Then I see defensive reactions about how we should be kind to each other. Honest advice by someone who knows what they are doing I feel is much more helpful then a feelings check and being politically correct. Giving the hard advice and educating seems to be frowned upon. The bottom line is that these complications are becoming more common in the literature as more poorly trained people are placing implants, so keep taking the courses, buying the gadgets and posting the close calls. It's okay as long as I don't hurt the doctors feelings and don't educate anyone especially if it keeps them from harming a patient. So let's just keep patting ourselves on the back even when a doctor is venturing into trouble it's okay no one is perfect! If one wants to truly be a surgeon then hard criticism needs to be heard and learned from. So I guess one has to learn the hard way unfortunately for the trusting patient. Fools ignore sage advice. Good luck you will most likely hear very little from me in the future since my honest advice is not appreciated and I get a lecture about his it us given so logically the value us being missed.
DrShalash
3/18/2014
Yes a CT is definitely advisable to see what ground u stand on. A limited mouth opening is a relative contraindication for placing a dental implant. was there an option to use short implant drills? what do u mean by perforated less than 20%. if its perforated, then its perforated. Good Luck
perio
3/18/2014
CBCT is highly advised before making another potential mistake. and remember, "when you are in doubt, STOP!" it is well worth it.
you are doing yourself and the patient a big favor and they would appreciate it.
GTF
3/19/2014
Post-op CT: yes, so you can determine whether or not it is worth restoring.
Perf more or less than 20% is a scary question. If you are thinking that this is the border beyond which you should not restore it, then CBCT will give you the answer you seek, and good luck. The question itself makes it clear that you need to restructure your approach to treatment planning so you are in control all the way instead of wondering what happened after the fact. Lingual perforation in the posterior mandible is nothing to be casual about - nick a lingual artery and see what kind of a day you have after that. CBCT first. As for Bicon, referral to someone who does Bicon is NEVER a good idea, as nobody should be "doing Bicon" in the first place. (lack of prosthetic flexibility; lack of management options in the event of peri-implantitis). If you lack a clear vision from start of surgery to completion of prostho, then you should refer the case - and you should feel good about it when you refer. Implant therapy is powerful, but stay within your comfort zone or end up like Icarus.
J. W
3/19/2014
Thank you for your replies. I also appreciate ALPC's kind remarks about being respectful when responding.
Sorry for delay in posting the follow-up:
I did order a sectional post-op CT the day after I submitted the post, and the lingual plate is intact. The tip of the implant is slightly engaged the internal aspect of the cortical plate, but there is no perforation. It is also in a restorable position relative to the opposing tooth even though it is placed more lingual than what I would have liked.
I should not have been careless, and there is no excuse b/c as a healthcare provider, I am dealing with another person's well-being. I am just very grateful that there is no perforation and most importantly, that the patient is feeling fine and that there is no complication for him.
This case will always serve as a reminder for me (and hopefully for others too) about the importance of pre-op planning and for always being alert and aware about the anatomical limitations and the consequences of violating their boundaries.
I sincerely value all your input. Thank you for this forum and for others who have also posted their questions--I agree with the moderator in that it is not always easy to admit to errors and for sharing one's mistakes, but it is a good way to learn and to avoid future mistakes.
Best, John
CRS
3/20/2014
Dear John, I would be very careful in case selection and only do straight forward cases with a lot of bone. Work closely with a trusted colleague on more complex cases. This is probably not worth the thrill of playing surgeon. More time could be wisely spent on treatment planning and restoring these cases. It will also be more profitable for your practice unless you are charging extra for all the post op visits and complications. One big mistake or lawsuit will ruin your practice. It is not easy placing implants but well placed implants are easy and profitable to restore, everybody including the patient wins. I do hear your sincerity and conscience. Good Luck I hope you take my advice and benefit from it, good luck.
GTF
3/20/2014
Lots of tough love in the above. John gets props for posting and good follow-up. CRS tells it like it is, but nobody is born knowing all this stuff. I perfed two out of 6 posterior mandibular implants on my first case in 1989. Fortune smiled and restoration was uneventful. Consider a simple "periapical" radiograph for diagnosis of perf (you can't always get a CBVT image). If you see a "periapical" (deep end of the implant) radiolucency that looks like an abcess around a tooth, then you perfed the plate. I've seen many perfed cases over the years (including mine, as I said) and no restorative problems, so don't be too quick to throw in the towel on the reconstruction just because you have a small perf. John - you are keeping your eyes open, and as a result you have a bright future. Keep posting and don't lose any stomach lining over what you read here - we all take a beating now and then and in the long run it is good for us - there really is no other way to learn (someone will disagree, but that is my experience).
John
3/20/2014
Thank you so much for your advice, CRS. I do value your opinion, and it's good to remember that it's Ok to say "no" to certain cases too.
CRS
3/20/2014
You are very welcome. I think the most critical part is the restoration and I respect your restorative skills. It truly is restoratively driven surgery, we can help each other!
Gordon Townsend
3/20/2014
As a general dentist, I have had to reduce fixation screws placed by oral surgeons that had perforated the lingual plate by several mm. No patient so far was informed of the occurrence, but were identified during routine prophy exam. Simple flap and reduction were all that were necessary. No CT was even considered. Lingual plate perforation is always possible when working in the posterior mandible. A simple digital (finger) exam of the lingual contours preop is very helpful, and all that is necessary to detect a perforation. If you have a perforation that is well covered by soft tissue, go with it. I have found several with long term (years) duration completely asymptomatic. The patient was informed and the area followed.
You're doing great. Keep up the reading and CE and enjoy implants.
John
3/20/2014
Hi George, Thank you so much for your advice and for sharing your experience. Hopefully with more experience, something like this will not happen again. It's a good "scare" for me actually so I will be more careful in the future. Again, just really thankful there was no actual perf....
