Lingual perforation and post op pain: how would you handle this case?
I have just examined a patient who had 8 implants installed in the mandible by another dentist in the #18, 19, 22, 25, 26, 27, 31, 30 sites [mandibular left second and first molars, left canine, left central incisor, right central incisor, right canine, right second and first molars; 37, 36, 33, 31, 41, 43, 46, 47].
The implants were installed in two stages with the first stage for posterior implant installation and the second stage for anterior implant installation. The patient started getting a lot of pain originating from the premolar region and radiating to central incisor area on the left side. The dentist who installed the implants was out of town and she told me to look into the case. I got a CBCT done and found that all the implants on left side had perforated the lingual cortical plate. However the implants were not close to mental foramen, but I saw an osteotomy had been performed and later not used above mental foramen but about 3 mm above mental foramen on the left side [#20, 21 area]. Since patient gave the history of no pain after posterior implant installation and and severe pain only after anterior implant installation, I removed the anterior implants.
However even after 10 days after implant removal the patient still complained of severe pain especially during night originating from mental foramen region and burning in the anterior area. Despite my advise, the original dentist who installed the implants, did not remove the posterior implants. What do you think caused the pain? Did I do the right thing in removing the anterior implants? Did I act prematurely? How would you have handled the case?
22 Comments on Lingual perforation and post op pain: how would you handle this case?
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CRS
2/5/2013
Refer the patient to a trusted OMS who treats mandibular paraesthesia he will be able to properly document the case clinically. Then call your malpractice company. You don't want to get involved in a colleagues complication. There is something unusual going on here, it is too early for a dysethesia (pain) one should expect a paresthesia in the lip and chin area not pain. You are in over your head. This may resolve with time but you really need to refer it appropriately, now you are involved since you removed another pracitioners work, without a diagnosis. while the operating doctor was out of town. This is a case to get appropriate consultation. Document everything, if it gets worse you are covered. There could be a traumatic neuroma and the appropriate specialist needs to treat this. Good Luck.
alupigus
2/5/2013
You def. did the right thing by removing implants to ease the pt´s pain!
just from telling, even with an xray, it´s hard to say, bc we don´t know what happend during surgery. An osteotomy 3mm above the foramen seems very unlikely to be the cause.
what i would take as an absolutely blind guess just by trying to read between the lines, might be a too tiny osteotomy compared to a larger, aggressive & active implant which was then wedged into that site (like nobel active), causing high tension on the bone and that way also on nerve structures. this is quite easy to figure out just by backing off the implants by 1/2 or 1 revolution.
personally, i think that a lot of implants perforated the lingual plate in the past but we just didn´t know as we haven´t had cbct in the past, and still there was not such pain as you described associated with perforation of the lingual plate.other issues were known (like severe bleeding etc.).
so if u want to give an advise to the initial doc: is trying to back off and see the pt the next day (perhaps associated with dexamethasone infiltrations to help), if it´s not an relief then take them out.
good luck.
keep us posted
CRS
2/6/2013
Alupigus, now you have just married the patient and the problem. The consulting expert should determine the proper response not another dds with the same level of expertise. Now it is damage control and this doctor needs to get appropriate help for the patients best care and outcome . Blind guesses are not much practical help.This is an unusual case with the operating doctor causing harm multiple perforations!
alupigus
2/6/2013
those able of reading have a clear advantage....nothing to add
Robert J. Miller
2/6/2013
There are actually two issues here. The first involves the anterior implants and the relationship to dysesthesia (not parathesia). These implants probably transected the neurovascular bundle anterior to the mental foramen known as the incisive branch. The result of this injury is to produce ALTERED sensation, not parasthesia of the lip or chin since it is anterior to the sensory branches to these areas. The injured branch then undergoes Wallerian degeneration, resulting in pain or a burning sensation.
The second issue is perforation of the lingual cortex. Even if there are no critical structures involved, there is still a long term problem. The floor of the mouth has tremendous mobility as a result of the action of the tongue. This mobile tissue will continue to rub on the roughened apex of the implants. The clinical outcome is to produce an inflammatory reaction: in this case NOT pathogen mediated, but rather microtrauma mediated. The cellular response, regardless of the etiology, is almost identical. Soft tissue swelling, inflammatory infiltrate, and continued bone loss will occur and the patients will never heal without definitive treatment. Depending on where the perforation has occured, there are three potential treatments. First is grafting over the site if not too deepiin the floor of the mouth. Second is apical resection of the exposed portion of the implant. And third, usually the treatment of choice, is implant removal.
RJM
OMS resident
2/10/2013
This sounds a bit far out... Could you be kind and support your theory of "lingual rubbing" with some scientific references?
greg steiner
2/12/2013
Dr. Miller I agree with your connection between perforation and inflammation. I have seen this in palatal and buccal mucosa tissue and I would think as you have stated that movement of tissue in the area of the perforation would accentuate the problem. I have found these lesions resolve after removing the perforated portion of the implant and grafting. The swelling and inflammation often does not show up until the implant is integrated and restored so sometimes removing the perforation is the least traumatic approach. Greg Steiner Steiner Laboratories
CRS
2/6/2013
You are all in over your heads. You don't have a diagnosis and are just guessing. There are few OMS that do nerve repair, this case needs to be managed by someone who does. If it were your lip or pain I think you would want to be followed by an expert.You need to be practical the above advice is not going to help you. Another doctor had an "unexpected" outcome and now you are heading down the path of "unexpected" outcome. The above posts show a lack of knowledge and expertise in this are and I am not going to educate them. These folks would fold in front of this situation or if they were deposed. They are just telling you how smart they think they are and they are not helping the situation. Don't be guilty of failure to refer, I 've advised you and a wise man takes good advice. I am sorry if I bruised a few egos they will heal by secondary intention! I bet in their hearts they know this is good advice but we all have free will. I hope that this patient recovers under expert care, you rarely get a second chance with nerves there is a window of opportunity and all these thing suggested are not going to change that. I also hope that both practioners learn from this. As Clint Eastwood said "a man has to know his limitations" Good Luck.
alupigus
2/6/2013
first think, then look in the mirror, then talk!
I know RJM for a few decades and there is nothing wrong with his statement, not less as with mine.
we have more or less about the same level of knowledge, i must admit, yes, which seems to be quite far above yours...
this doc, was posting just a question, knowing that he is not giving all the data needed to give a final verdict and therefor expecting non-educated guesses based on nothing else than a rough outline expecting to get and actually looking for statements just like bob´s or mines. perhaps there was no such initial doc placing the implants other than himself...like that typical "hey doc, i´ve got a friend having this and that problem..."
your oms-like comments where "i place the implants where the bone is, the lab will have to fix the prosthetics I don´t know & I don´t care" and refer it out to somebody like me who can fix nerve nerve damage ( as if there would be such a doc being able of fixing nerve damages-who do you think you are talking to?).
i am sick & tired of oms stating all the time: "refer, refer, refer, refer, refer" so they got business by starting out with "who did this to you" and "sorry, there is nothing left i can do for you, go see a lawyer"...
go get a life!
CRS
2/6/2013
Dear Dr, I obviously hit a nerve here, not my intention. I stand by my saga advice, sorry you took this personally. It is really good advice. You have really no idea what my level of experience is, but based on your reaction I made you defensive. I can't educate through the defensive comments, but look at this case realistically. I don't know where you practice or what your resources are but that's how I advise handling this. I honestly don't understand the resentment towards OMs which has nothing to do with my advice, just trying to help a colleague. Based on your posts I stand by what I said respectfully I think that the case should be managed that way and I am entitled to my opinion which was submitted in a respectful and honest way. There are methods to evaluate nerve damage and repair or follow it. Perhaps this patient will seek these answers on their own, not thru an online implant blog thru semi-anonymous posters, be realistic. Thank you for reading!
CRS
2/8/2013
I don't like to assume my critics are wrong, get angry or upset , but I like to take that opportunity to examine my comments.I like to thank my critics because they help me see things that others would not. I think it is important to have a positive attitude towards correction as well as everything in life. Only a fool hates correction. Anyway I sincerely hope that the poster gets appropriate consultation and has the case followed by an expert for the best possible outcome for all involved. Thanks for reading!
Cliff Leachman
2/12/2013
I really like "the egos healing by secondary intention"!
greg steiner
2/12/2013
While we need to read between the lines it appears that the pain did not start immediately after the surgery. If it was nerve damage you would think the treating doctor would have never made it out of town. While, yes, we are all guessing but another possibility is a periapical infection. Greg Steiner Steiner Laboratories
Suhas Vaze ( OMFSurgeon
2/12/2013
Pain, however severe can be controlled with analgesics. Pressure on the osteotomy site will eill be allright with time and healing. The idea of lingual rubbing of soft tissues seems far fetched. Grafting on the lingual side is easier said than done.
Suhas Vaze
Bruce G. Knecht
2/13/2013
From our hardships comes learning. Once this happens, think , what would I have done differently to prevent this. I love Robert's explanation and this could be true. However, learn and yes I sometimes forget to probe the osteotomy before placing the fixture. Just take a blunt probe that comes with most surgical kits and feel for soft spots. If you feel this stop and redirect the drill. it is a simple thing that we for get to do. When we inherit other people's problems, information can be ommitted. I would take to the original Dr. and go through what happened step by step. It could be the surgical technique.
CRS
2/14/2013
I think this very good advice you can run your finger along the lingual or buccal cortex also to feel the probe for perforation. Also you can get a rush of bleeding from the soft tissue. Was this a flapless technique?
Dr. Yaron Miller
2/13/2013
I would like to make the comment that you would have been far better not touching this case in the first place. Why would you want to get involved in removing someone else's implants after you saw lingual perfs. What could the possible benefits be? This to me would have been a red flag and an immediate "sorry this is way to complex, you need to see a specialist". I wish you the best of luck and hope this goes away.
Robert J. Miller
2/16/2013
To all of the posters who believe that microtrauma induced soft tissue inflammation does not exist, you either have not done enough implant cases or don't get failures sent to your office for revision. This is a REAL phenomenon, one that we have seen many times where mobile tissue rests on a roughened implant, be it in the floor of the mouth or in the maxilla where there is alveolar mucosa being pulled by a frenum attachment. There is constant redness, discomfort, and, in some cases, a CLEAR serous exudate as a result of lymphatic drainage. Where there is an inflammatory cascade, either pathogen or microtrauma induced, you will get all of the classic sequelae including ultimate bone loss. When you have a symptomatic case, we have never seen resolution by "secondary intention". If only the apex of the implant has perforated, you have a better chance of healing. However, if the body has also perforated, more definitive treament is indicated. But the suggestion that microtrauma mediated inflammation does not occur is just flat out wrong.
RJM
CRS
2/17/2013
I like your explanation, look at it logically, there is no benefit for placing an implant through the lingual plate ie better stabilization etc. patients will tolerate a bone screw or a k-wire for a short period of time during a fracture or bone plate and are removed after healing. Most likely the constant movement if the mylohyoid muscle is your culprit during swallowing or the genioglossis with tongue movement. Anyway it is a good explanation and a good understanding of what is tolerable in the mandible if you get past the lingual bleeding and paresthesia, a long term sequela.. I like to keep it simple don't perforate the lingual, respect the surgical boundaries and you will benefit the patient. It is surgery 101. Welcome to my world, if the other posters disagree they don't get it, you do! A lawyer would have a field day with this case . Thank you for reading.
Richard Hughes, DDS, FAAI
2/17/2013
Robert, thank you for the explanation.
Amit Gaba
2/24/2013
Dr. Robert J. Miller
you are amazing ....All your axplanations are up to the mark.I think these explantions should be published...so that other implantologists can be benefitted from them.
best of luck
CRS
2/24/2013
Yeah Robert, pick a journal and go for it!!
