Implant Patient with Post Op Parasthesia: Consensus Treatment?
Dr. G asks:
After 20+ years and 1,000’s of implants I finally have a patient with a post op parasthesia. I’d like to get a consensus on treatment.
The implant was placed in site #30. Infiltration anesthesia only. Osteotomy was prepared in stepwise fashion and on the final drill the patient began to feel a tingle. The implant was placed definitely above the canal. However, I can see a shadow of a perforation through the top of the canal by the drill in the check film.
I called the patient 8 hours post surgery and as expected he had a small numb area on the top of his lip. He reported about 2 teeth wide.
So my question is, steroids remove implant? Or wait and steroids? Or any other suggestions. I am sure the implant is above the canal.
17 Comments on Implant Patient with Post Op Parasthesia: Consensus Treatment?
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JIM
3/8/2012
How about a medrol dose pak and try reversing the implant a 1/4 or 1/2 turn.
Arne
3/9/2012
At court question may be placed if it could have been any better after impl removal and medication. No expert could credibly exclude that hypothesis. So, removal and medication is mandantory in order to prove that nothing was missed out in order to bring relief in that undesirable but possible case of nerve injury during implant placement.
Medication: Plenty of flushing the osteotomy after implant removal with Dexamethasone. Also inject Dexa apical to the osteotomy into into the soft tissues, and give it also as usual (decreasing doses). Also Nicergolin (i.e.Sermion) has shown positive effects.
For legal resons it could be helpful to refer the pat to an OS.
Good luck!
OMS resident
3/9/2012
Arne - flushing the osteotomy with the dexamethason? Seriously? And local injections in the soft tissue? Why don't you just expose the neurovascular bundle and inject steroids directly in the perineurium? C'mon...
If the question is about decompression, implant removal may be the appropriate intervention. P.O. steroids can be helpful to a certain degree if it is administrated within 48 hours after injury. But, again I have a limited experience in this field and the cases I've treated has been worse than dr. Gs case. I find the literature a bit vague on the subject.
I know there's been a couple of discussions on the subject already, but a "consensus" could be helpful: Drs. Hughes, Miller, Vinci et al?
And again, referral should be discussed due to legal issues.
Mario Marcone
3/9/2012
Although the literature is perhaps somewhat limited on this matter, it may be helpful to use some intuitive sense on treating these complications. I think Arne was referring to local injection into soft tissue only, not into bony tissue, but at a level at or apical to the
osteotomy, in addition to intra-osteotomy flush with dexamethasone. Let's think about the possible topical effects of such a local application near the affected area of concern, in addition to systemic administration. Nothing wrong with this at all ... medical practitioners use topical corticosteroids routinely. This approach definitely cannot hurt the patient, so I personally would not vehemently dismiss the idea.
MM
expert
3/9/2012
Referal is a good option, especially when taking care of to what resident with limited experience you are about to refer to...
OMS resident
3/10/2012
Maybe I was a bit to vague. The cases I've seen regarding dental implants and the inferior alveolar nerve have been cases where the neurovascular bundle has been partially or completely transected by the implant. We removed all implants (decompression) and the patients were then evaluated for possible microsurgical nerve repair. I would these cases more severe than the actual case presented by dr. G. So, yes I have a limited experience with "minor" nerve damages caused by elective dental implant surgery. On the other hand, nerve damages due to facial trauma and reconstruction, orthognathic surgery and after removal of wizzies do occcur, though unfortunately for the patients. Luckily most are simple paresthesia or hypoesthesia and they heal spontainiously after some time. Dr. Hughes - thanks for the literature references!
OMS resident
3/10/2012
Couple of typos in my recent post - sorry! iPads can be vicious...
Richard Hughws DDS, FAAID
3/9/2012
OMS Resident: The literature is sketchy at best. Block and Kent's Implant text has a good chapter on this topic. Hom-Lay Wang et al., and R Bruce Donoff, have written good papers on this topic. These may be a good start to understand the cause, progress, prognosis and treatment. When in doubt refer and quickly.
Jim
3/9/2012
problem with injecting any steroid directly into tissue can cause atrophy and damage to surrounding areas.....fine line using this injectables over oral administration.
Richard Hughes, DDS, FAAI
3/9/2012
JIM; This is ok but if it does not improve, then remove and irrigate and upgrade the steroid. Also, take radiographs (pa, pano, cbct). When in doubt refer, the sooner the better. Remember V3 is a mixed nerve (motor, sensory and autonomic). The best treatment is prevention. Check out Misch's "ZONE OF SAFETY".
jim
3/10/2012
Good points....will make sure to check it out
Dr. D Kevin Moore
3/13/2012
Just a humble response:
remove, medicate, refer... all in the same hour....
expert
3/13/2012
excellent point!!!!!!!!!!
Theodore Grossman DMD
3/13/2012
"The implant was placed definitely above the canal. However, I can see a shadow of a perforation through the top of the canal by the drill in the check film."
O.K., trauma was caused by the trephine resulting in limited( small numb area) paresthesia. If you can obtain a quality CBCT without "starburst", document the nerve trauma using OMSNIC's neurological exam format for progress reports. If there is minimal sheath damage, I would give it time to resolve.If damage is greater than expected make your decision about removal and referral. Let the patient know the worst & best case senario, and the potential healing time.
IMHO
Baker vinci
3/14/2012
If you are certain, that you just invaded the canal, then you are most likely dealing with a simple neuropraxia. This I why you need the pre-op ct and must still perform intraop pa's. If you didn't get bleeding at the sight, then I would bet your patient will be ok. The first response is reasonable, but I would probably give more than a Medrol dose pack. Intentionally injecting the nerve, with anything is ill-advised . Regardless, the damage is done, so make sure you are'nt compressing the nerve, now. Based on what I'm reading, if your patient doesn't see quick resolve( in the amount of time that normal surgical swelling comes and goes), then refer, to an specialist , in nerve repair. Hey expert, are you prepared??? Aren't you kind of asking for it? Bv
Dr G
3/20/2012
Thanks for all the comments. By 24hours the patient had already regained some sensation upon stimulation to his lip and gingiva in the area with prior numbness. By 7 days post op there was a definite decrease in the area of parasthesia. Based on his progress I am encouraged.
As a follow up to the experts, what would you expect the chances of a nerve repair being successful in cases of severe damage. I work frequently with Dr. Donoff on other types of surgical procedures and in conversation he reports the usual goal of any of the nerve "repair" surgeries is to essentially stop hyper anesthesia states, ie burning or chronic pain by destroying the nerve.
Baker vinci
3/21/2012
Bruce D. has forgotten more about nerve injury/ repair and function, than all of us know. At the expense of being redundant. If you backed the implant back a 1/2 turn and waited, then you did the right thing. This will never be a nerve surgery candidate, most likely. I would expect full recovery, if not, your patient will most likely regain most sensation without pain. Good job! Bv
